Incidence Of Ventilator-associated Pneumonia In Patients Research Articles

Comparison of the Effects of Open and Closed Endotracheal Suction Systems on Ventilator-Associated Pneumonia and Mortality

Aims: Nosocomial pneumonia is a prevalent complication in patients admitted to intensive care units. Endotracheal suction (ES) is used to clean the airways of secretions in patients under mechanical ventilation (MV). The objective of this study was to compare the effects of an open endotracheal suction system (OESS) versus a closed endotracheal suction system (CESS) on the incidence of ventilator-associated pneumonia (VAP).
 Study Design: Retrospective examination of hospital records.
 Place and Duration of Study: Reanimation Intensive Care Unit, Van Training and Research Hospital, Van, Turkey, between January 2018 and December 2019.
 Methodology: Age, gender, and length of stay in the intensive care unit and under mechanical ventilation (MV), mortality and isolated microorganism status of 73 (35.6%) patients with VAP were analyzed retrospectively. These features were compared according to the ES type applied. Sample: The study was conducted among 205 patients who were connected to a mechanical ventilator for more than 48 h in the reanimation intensive care unit (RICU) of a tertiary care hospital.
 Results: There was no difference between OESS and CESS groups in terms of mortality rates, length of stay in the RICU, and duration of MV. There was a significant difference in terms of incidence of VAP between the OESS group and the CESS group (41.8% and 29%, respectively; P = .045) Acinetobacter baumanii was the most frequently isolated microorganism in both groups.
 Conclusion: CESS treatment was associated with a lower incidence of VAP in patients of the RICU.

The effect of an infection control guideline on the incidence of ventilator-associated pneumonia in patients admitted to the intensive care units

Background and aimStandard airway care can reduce the incidence of ventilator-associated pneumonia (VAP). This study aimed to determine the effect of implementing infection control guidelines on the incidence of VAP in patients admitted to the intensive care unit (ICU).Materials and MethodsIn this clinical trial, 121 patients admitted to the intensive care units of Golestan and Imam Khomeini hospitals of Ahvaz, Iran who were under mechanical ventilation were assigned to two groups of control and intervention in non-randomly allocation. The study was conducted in two consecutive periods. In the intervention group, infection control guidelines were performed to prevent VAP and in the control group, routine care was performed. Data collection is done by used a three-part instrument. The first part included questions on the patients’ demographics and clinical information. The second part was the modified clinical pulmonary infection scale (MCPIS) for the early detection of VAP. The third part of the data collection instrument was a developed checklist through literature review. The MCPIS was completed for all patients on admission and the 5th day of the study.ResultsThe two groups were homogenous respecting their baseline characteristics (P > 0.05) including the mean MCPIS score (P > 0.05). However, the intervention group had lower body temperature (P < 0.001), lower white blood cell counts (P < 0.038), lower MCPIS score (P < 0.001), and higher PaO2/FIO2 (P < 0.013) at the end of the study. The incidence of VAP was significantly lower in the intervention group when compared to the control group (i.e. 30% vs. 65.6%, P < 0.001).ConclusionsThe implementation of infection control guidelines could significantly reduce the incidence of VAP and its diagnostic indicators in patients admitted to the ICU. Nurses are advised to use these guidelines to prevent VAP in patients admitted to ICU.

Meta-Analysis of the Efficacy and Safety of Chlorhexidine for Ventilator-Associated Pneumonia Prevention in Mechanically Ventilated Patients.

Objective To explore the efficacy and safety of chlorhexidine oral care in the prevention of ventilator-associated pneumonia (VAP) by means of meta-analysis. Methods Randomized controlled trials on the effect of chlorhexidine oral care on the incidence of VAP in patients on mechanical ventilation were searched in PubMed, Scopus, Cochrane Library, and Embase from May 1, 2022. Two researchers independently screened and included the study, extracted the data, and evaluated the literature quality. RevMan5.3 software was used for meta-analysis. Results Meta-analysis of 13 included literature studies involving 1533 patients showed that oral care with chlorhexidine solution could reduce the incidence of VAP in patients with mechanical ventilation and the difference was statistically significant (RR = 0.61, 95% CI (0.46, 0.82), P=0.04). However, the results showed that the incidence of VAP of low concentration (0.02%, 0.12%, and 0.2%) and high concentration (2%) of chlorhexidine in the intervention group was lower than that in the control group and the difference was statistically significant (RR = 0.70, 95% CI (0.51, 0.96), P=0.03; RR = 0.41, 95% CI (0.27, 0.62)). There was no significant difference in mortality between the two groups (RR = 1.01, 95% CI (0.85, 1.21), P=0.87). There was no statistical significance in days ventilated or days in ICU between the two groups (RR = −0.02, 95% CI (−0.19, 0.16), P=0.84; RR = 0.01, 95% CI (−0.11, 0.14), P=0.85). Conclusion Existing evidence shows that chlorhexidine used for oral care of patients with mechanical ventilation can reduce the incidence of VAP, and high concentration of chlorhexidine (2%) or low concentration of chlorhexidine (0.02%, 0.12%, 0.2%) has a significant effect on the prevention of VAP. Considering the safety of clinical application, it is recommended to use 0.02%, 0.12%, and 0.2% chlorhexidine solution for oral care.

Epidemiology and microbiology of ventilator-associated pneumonia in COVID-19 patients: a multicenter retrospective study in 188 patients in an un-inundated French region

BackgroundThe COVID-19 pandemic is responsible for many hospitalizations in intensive care units (ICU), with widespread use of invasive mechanical ventilation (IMV) which exposes patients to the risk of ventilator-associated pneumonia (VAP). The characteristics of VAP in COVID-19 patients remain unclear.MethodsWe retrospectively collected data on all patients hospitalized for COVID-19 during the first phase of the epidemic in one of the seven ICUs of the Pays-de-Loire region (North-West France) and who were on invasive mechanical ventilation for more than 48 h. We studied the characteristics of VAP in these patients. VAP was diagnosed based on official recommendations, and we included only cases of VAP that were confirmed by a quantitative microbiological culture.FindingsWe analyzed data from 188 patients. Of these patients, 48.9% had VAP and 19.7% experienced multiple episodes. Our study showed an incidence of 39.0 VAP per 1000 days of IMV (until the first VAP episode) and an incidence of 33.7 VAP per 1000 days of IMV (including all 141 episodes of VAP). Multi-microbial VAP accounted for 39.0% of all VAP, and 205 pathogens were identified. Enterobacteria accounted for 49.8% of all the isolated pathogens. Bacteremia was associated in 15 (10.6%) cases of VAP. Pneumonia was complicated by thoracic empyema in five cases (3.5%) and by pulmonary abscess in two cases (1.4%). Males were associated with a higher risk of VAP (sHR 2.24 CI95% [1.18; 4.26] p = 0.013).InterpretationOur study showed an unusually high incidence of VAP in patients admitted to the ICU for severe COVID-19, even though our services were not inundated during the first wave of the epidemic. We also noted a significant proportion of enterobacteria. VAP-associated complications (abscess, empyema) were not exceptional.RegistrationAs an observational study, this study has not been registered.

Duration Of Ventilation Support Usage And Development Of Ventilator-Associated Pneumonia: When Is The Most Time At Risk?

Introduction: Ventilator-Associated pneumonia (VAP) is pneumonia that occurs in patients who have been mechanically ventilated for a duration of more than 48 hours. The duration of ventilator use was identified as a risk factor which is a trigger of VAP. Objective: This study aimed to determine the association between the duration of ventilator use and the incidence of VAP in patients in the Intensive Care Unit of Dr. Mohammad Hoesin General Hospital, Palembang. Method and Material: This study was an observational analytic study using a cross-sectional design. The samples were all patients who use a ventilator for more than 48 hours at the ICU room period of July 1, 2014, to June 30, 2015. Data were obtained from the patient’s medical records of a total of 146 patients, but the number of patients who comply with the criteria was 106 patients. Result and Discussion: Out of the 106 samples, 41 patients (38.7%) developed VAP and 65 patients (61.3%) did not develop VAP. The analysis using Chi-Square test showed that patients who used ventilator for &gt;5 days had an OR = 3.273 compared to patients using ventilator 2-5 days (p-value = 0.016; 95% CI = 1.223 to 8.754). Conclusion: There is a significant association between the duration of ventilator use and the incidence of VAP in patients at the ICU of Dr. Mohammad Hoesin General Hospital, Palembang. Patients using ventilators for more than 5 days 3,386 times more at risk of developing VAP compared to patients using ventilators 2-5 days. The riskiest time for the patient using ventilator was more than 5 days of usage. And, the mortality rate of VAP patients was 63.4% from 41 patients while the mortality rate of whole ICU patients was 50.9%.

Effects of angle measuring device and reminding device on head-of-bed elevation compliance and decreasing the incidence of VAP in patients with mechanical ventilation

Objective To improve the nurses' compliance of elevating the head-of-bed of patients with endotracheal intubation or tracheostomy tube using mechanical ventilation, who had no contraindications of head-of-bed elevation by the installation of angle measuring device and reminding device for head-of-bed elevation, so as to reduce the incidence of ventilator-associated pneumonia (VAP) . Methods A total of 575 and 473 cases of patients with endotracheal intubation or tracheostomy tube using mechanical ventilation were selected respectively rom the patients who were hospitalized in Tengzhou Central People's Hospital in Shandong Province in the year of 2014 and 2016. In 2014, before intervention, the implementation of cluster nursing and the general monitoring data of VAP were comprehensively grasped. In 2015, a total of 26 beds in ICU were installed with angle measuring device and reminding device for head-of-bed elevation. In 2016, after intervention, the implementation of cluster nursing and the general information level of the monitoring data of VAP were collected. SPSS 17.0 software was applied for data statistical analysis before and after intervention. Results The nurse compliance of head-of-bed elevation for mechanical ventilation patients was improved after intervention (χ2=1 691.675, P<0.001) , as well as the incidence of VAP significantly decreased (χ2=9.248, P=0.002) . The incidence of VAP millennium catheterization decreased, but the difference was not statistically significant (χ2=2.694, P=0.058) . Conclusions The installation of bed angle measuring device and reminding device can effectively improve nurse compliance of head-of-bed elevation in patients with mechanical ventilation and reduce the incidence of VAP. Key words: Intensive care unit; Respiration, artificial; Ventilator-associated pneumonia; Head-of-bed elevation; Compliance

Efficacy of Hi-Lo Evac Endotracheal Tube in Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Poisoned Patients.

Background. Ventilator-associated pneumonia (VAP) is the most common health care-associated infection. To prevent this complication, aspiration of subglottic secretions using Hi-Lo Evac endotracheal tube (Evac ETT) is a recommended intervention. However, there are some reports on Evac ETT dysfunction. We aimed to compare the incidence of VAP (per ventilated patients) in severely ill poisoned patients who were intubated using Evac ETT versus conventional endotracheal tubes (C-ETT) in our toxicology ICU. Materials and Methods. In this clinical randomized trial, 91 eligible patients with an expected duration of mechanical ventilation of more than 48 hours were recruited and randomly assigned into two groups: (1) subglottic secretion drainage (SSD) group who were intubated by Evac ETT (n = 43) and (2) control group who were intubated by C-ETT (n = 48). Results. Of the 91 eligible patients, 56 (61.5%) were male. VAP was detected in 24 of 43 (55.8%) patients in the case group and 23 of 48 (47.9%) patients in the control group (P = 0.45). The most frequently isolated microorganisms were S. aureus (54.10%) and Acinetobacter spp. (19.68%). The incidence of VAP and ICU length of stay were not significantly different between the two groups, but duration of intubation was statistically different and was longer in the SSD group. Mortality rate was less in SSD group but without a significant difference (P = 0.68). Conclusion. The SSD procedure was performed intermittently with one-hour intervals using 10 mL syringe. Subglottic secretion drainage does not significantly reduce the incidence of VAP in patients receiving MV. This strategy appears to be ineffective in preventing VAP among ICU patients.

Effect of a fever control protocol-based strategy on ventilator-associated pneumonia in severely brain-injured patients.

IntroductionFever is associated with a poor outcome in severely brain-injured patients, and its control is one of the therapies used in this condition. But, fever suppression may promote infection, and severely brain-injured patients are frequently exposed to infectious diseases, particularly ventilator-associated pneumonia (VAP). Therefore, we designed a study to explore the role of a fever control protocol in VAP development during neuro-intensive care.MethodsAn observational study was performed on severely brain-injured patients hospitalized in a university ICU. The primary goal was to assess whether fever control was a risk factor for VAP in a prospective cohort in which a fever control protocol was applied and in a historical control group. Moreover, the density of VAP incidence was compared between the two groups. The statistical analysis was based on a competing risk model multivariate analysis.ResultsThe study included 189 brain-injured patients (intervention group, n = 98, and historical control group, n = 91). The use of a fever control protocol was an independent risk factor for VAP (hazard ratio 2.73, 95% confidence interval (1.38, 5.38; P = 0.005)). There was a significant increase in the incidence of VAP in patients treated with a fever control protocol (26.1 versus 12.5 VAP cases per 1000 days of mechanical ventilation). In cases in which a fever control protocol was applied for >3 days, we observed a higher rate of VAP in comparison with the rate among patients treated for ≤3 days.ConclusionsFever control in brain-injured patients was a major risk factor for VAP occurrence, particularly when applied for >3 days.

Impact of appropriate antimicrobial treatment on transition from ventilator-associated tracheobronchitis to ventilator-associated pneumonia.

IntroductionTwo small randomized controlled trials have suggested beneficial effects of antibiotic treatment in patients with ventilator-associated tracheobronchitis (VAT). The primary aim of this study is to determine the impact of appropriate antibiotic treatment on transition from VAT to ventilator-associated pneumonia (VAP) in critically ill patients. The secondary objective was to determine the incidence of VAP in patients with VAT.MethodsThis was a prospective observational multicenter study. All patients with a first episode of VAT were eligible. Patients with tracheostomy at intensive care unit (ICU) admission, and those with VAP prior to VAT were excluded. VAT was defined using all the following criteria: fever > 38°C with no other cause, purulent tracheal secretions, positive tracheal aspirate (≥105 cfu/mL), and absence of new infiltrate on chest X ray. Only VAP episodes diagnosed during the 96 h following VAT, and caused by the same bacteria, were taken into account. Antibiotic treatment was at the discretion of attending physicians. Risk factors for transition from VAT to VAP were determined using univariate and multivariate analysis. All variables from univariate analysis with P values <0.1 were incorporated in the multivariate logistic regression analysis.ResultsOne thousand seven hundred and ten patients were screened for this study. Eighty-six, and 123 patients were excluded for tracheostomy at ICU admission, and VAP prior to VAT; respectively. One hundred and twenty two (7.1%) patients were included. 17 (13.9%) patients developed a subsequent VAP. The most common microorganisms in VAT patients were Pseudomonas aeruginosa (30%), Staphylococcus aureus (18%), and Acinetobacter baumannii (10%). Seventy-four (60%) patients received antimicrobial treatment, including 58 (47.5%) patients who received appropriate antimicrobial treatment. Appropriate antibiotic treatment was the only factor independently associated with reduced risk for transition from VAT to VAP (OR [95% CI] 0.12[0.02-0.59], P = 0.009). The number of patients with VAT needed to treat to prevent one episode of VAP, or one episode of VAP related to P. aeruginosa was 5, and 34; respectively.ConclusionsAppropriate antibiotic treatment is independently associated with reduced risk for transition from VAT to VAP.

The impact of a ventilator bundle on preventing ventilator-associated pneumonia: A multicenter study

For prevention of ventilator-associated pneumonia (VAP), a bundle approach was applied to patients receiving mechanical ventilation in intensive care units. The incidence of VAP and the preventive efficacy of the VAP bundle were investigated. A quasi-experimental study was conducted in adult intensive care units of 6 university hospitals with similar VAP rates. We implemented the VAP bundle between March 2011 and June 2011, then compared the rate of VAP after implementation of the VAP bundle with the rate in the previous 8 months. Our ventilator bundle included head of bed elevation, peptic ulcer disease prophylaxis, deep venous thrombosis prophylaxis, and oral decontamination with chlorhexidine 0.12%. Continuous aspiration of subglottic secretions was an option. Implementation of the VAP bundle reduced the VAP rate from a mean of 4.08 cases per 1,000 ventilator-days to 1.16 cases per 1,000 ventilator-days. The incidence density ratio (rate) was 0.28 (95% confidence interval, 0.275-0.292). Implementing the appropriate VAP bundle significantly decreased the incidence of VAP in patients with mechanical ventilation.

Effect of continuous oral suctioning on the development of ventilator-associated pneumonia: A pilot randomized controlled trial

BackgroundBoth continuous and intermittent aspiration of subglottic secretions by means of specially designed endotracheal tubes containing a separate dorsal lumen that opens into the subglottic region have been shown to be useful in reducing ventilator-associated pneumonia (VAP). However, the high cost of these tubes restricts their use. ObjectiveThe aim of this pilot randomized controlled trial was to test the effect of a low-cost device (saliva ejector) for continuous oral suctioning (COS) on the incidence of VAP in patients receiving mechanical ventilation. MethodsThe study was conducted in the six-bed medical-surgical ICU of a hospital with over 400 beds that provides comprehensive medical services to the public. The design of this study was a parallel-group randomized controlled trial. While both the experimental and control groups used the conventional endotracheal tube, the saliva ejector was only applied to patients assigned to the experimental group. The device was put between the patient's cheek and teeth, and then connected to 100mmHg of suction for the continuous drainage of saliva. ResultsFourteen patients were randomized to receive COS and 13 patients were randomized to the control group. The two groups were similar in demographics, reasons for intubation, co-morbidity, and risk factors for acquiring VAP. VAP was found in 3 patients (23.1%; 71 episodes of VAP per 1000 ventilation days) receiving COS and in 10 patients (83.3%; 141 episodes of VAP per 1000 ventilation days) in the control group (relative risk, 0.28; 95% confidence interval, 0.10–0.77; p=0.003). The duration of mechanical ventilation in the experimental group was 3.2 days (SD 1.3), while that in the control group was 5.9 days (SD 2.8) (p=0.009); and the length of ICU stay was 4.8 days (SD 1.6) versus 9.8 days (SD 6.3) for the experimental and control groups, respectively (p=0.019). ConclusionContinuous clearance of oral secretion by the saliva ejector may have an important role to play in reducing the rate of VAP, decreasing the duration of mechanical ventilation, and shortening the length of stay of patients in the ICU.

Efficacy of heat and moisture exchangers and heated humidifiers in preventing ventilator-associated pneumonia: a meta-analysis

To demonstrate the effects of heat and moisture exchangers (HME) and heated humidifiers(HH) in preventing ventilator-associated pneumonia (VAP). PubMed and Cochrane databases were searched by computer retrieval and manual retrieval to identify relevant randomized controlled trials (RCTs) using HMEs and HHs in preventing VAP from January 1st 1990 to September 1st 2010. Meta-analysis of HME and HH in preventing VAP was conducted using the methods recommended by the Cochrane Collaboration. Eleven RCTs were included. 1 121 in HME group and 1 101 in HH group. In total, the rate of VAP in HME group and HH group was 14.2% (159/1 121) and 15.9% (175/1 101) respectively, the total relative risk (RR) was 0.88, and 95% confidence interval (95%CI) 0.72-1.07, P=0.21. Compared with HH group, there was not a reduction in the risk ratio of VAP in the HME group. Even in mechanical ventilation(MV) with a duration of at least 7 days for subgroup analysis (8 RCTs, sample size: 834 in HME group and 859 in HH group), the rate of VAP in HME group and HH group was 15.2% (127/834) and 17.5% (150/859) respectively, the total RR was 0.84, 95%CI 0. 58-1.23, P=0.37, suggesting that in MV with a duration at least 7 days, there was also no reduction in the risk ratio of VAP in the HME group. This study suggests there is not a significant reduction in the incidence of VAP in patients humidified with HMEs during MV, even in patients ventilated for 7 days or longer. This finding is limited by lack of enough RCTs and blinding. Further large sample of high quality RCTs is necessary to examine the wider applicability of HMEs and their extended use.

Effect of ventilator bundle for prevention of ventilator associated pneumonia in the patients with malignant tumor

Objective To examine the effect of ventilator bundle on prevention of ventilator associated pneumonia (VAP) in patients with malignant tumor. Methods In this prospective study, 147 patients with malignant tumor in intensive care unit were received ventilator intervention with the head position elevated 30 degree, daily' sedation vacation' done and daily readiness to extubation assessed, prevention for peptic ulcer disease and deep venous thrombosis taken. Compared with the hospitalized patients before the intervention,mechanical ventilation time and incidence of VAP were analyzed. Results Compared with the control group,after the administration of ventilator bundle, the incidence of VAP decreased slightly, mechanical ventilation time shortened and hospital stay in ICU reduced dramatically. Conclusions Ventilator bundle could significantly prevent the incidence of VAP in patients with malignant tumor. Key words: Ventilator bundle; Maliqnant tumur; Ventilator associated pneumonia; Nursing

Probiotics for the prevention of ventilator-associated pneumonia

Evaluation of: Morrow LE, Kollef MH, Casale TB. Probiotic prophylaxis of ventilator-associated pneumonia: a blinded, randomized, controlled trial. Am. J. Respir. Crit. Care Med. DOI: 10.1164/rccm.200912-1853OC (2010) (Epub ahead of print).In a recently conducted randomized double-blind placebo-controlled trial, probiotics were compared with placebo in mechanically ventilated patients at risk for ventilator-associated pneumonia (VAP). Microbiologically documented VAP, Clostridium difficile-associated diarrhea and colonization by pathogenic bacteria were less frequent in probiotic-treated patients. We used this opportunity to update a relevant meta-analysis of similar trials. Using a random-effects model, we found a nonsignificant trend towards a lower incidence of VAP in patients treated with a probiotic formulation versus controls (seven studies, 994 patients; pooled odds ratio: 0.60; 95% CI: 0.35–1.02); all-cause mortality did not differ (six studies, 786 patients; odds ratio: 0.84; 95% CI: 0.59–1.18).

Adherence to Ventilator-Associated Pneumonia Bundle and Incidence of Ventilator-Associated Pneumonia in the Surgical Intensive Care Unit

To examine the impact of adherence to a ventilator-associated pneumonia (VAP) bundle on the incidence of VAP in our surgical intensive care units (SICUs). Prospectively collected data were retrospectively examined from our Infection Control Committee surveillance database of SICU patients over a 38-month period. Cost of VAP was estimated at $30,000 per patient stay. Two SICUs at a tertiary care academic level I trauma center. Ventilated patients admitted to a SICU. The Institute for Healthcare Improvement VAP bundle was instituted at the beginning of the study and included head-of-bed elevation, extubation assessment, sedation break, peptic ulcer prophylaxis, and deep vein thrombosis prophylaxis. A daily checklist was considered compliant if all 5 items were performed for each patient. Patients were assessed for VAP. Staff were assessed for compliance with the VAP bundle. Prior to initiation of the bundle, VAP was seen at a rate of 10.2 cases/1000 ventilator days. Compliance with the VAP bundle increased over the study period from 53% and 63% to 91% and 81% in each respective SICU. The rate of VAP decreased to 3.4 cases/1000 ventilator days. A cost savings of $1.08 million was estimated. Initiation of the VAP bundle is associated with a significantly reduced incidence of VAP in patients in the SICU and with cost savings. Initiation of a VAP bundle protocol is an effective method for VAP reduction when compliance is maintained.

Role of chlorhexidine gluconate in ventilator-associated pneumonia prevention strategies in ICU patients: where are we headed?

We read with interest the recent study by Scannapieco and colleagues [1], which concluded that twice-daily oral rinse with 0.12% chlorhexidine failed to reduce the number of potential respiratory pathogens in dental plaque, mortality, the incidence of ventilator-associated pneumonia (VAP), the length of intensive care unit (ICU) stay and the duration of mechanical ventilation in trauma ICU patients. Trauma ICU patients are similar to mixed ICU patients with respect to risk factors for developing VAP, unlike patients undergoing elective cardiac surgery. Use of 0.12% chlorhexidine decreases the incidence of VAP in patients undergoing elective cardiac surgery. In mixed ICU patients, chlorhexidine at concentrations less than 0.2% has consistently been shown to have no benefit [2]. A randomized trial using 2% chlorhexidine has, however, demonstrated a reduction in VAP rates in these patients [3]. A previous study showed that 12-hourly application of chlorhexidine has a sustained preventive effect on biofilm formation [4]. The lack of benefit from twice-daily oral cleansing with chlorhexidine in the present study may be due to the lower concentration of chlorhexidine. The authors' recommendation for investigation into mechanical plaque removal with chlorhexidine would conceptually have some added benefit. Mechanical plaque removal with chlorhexidine, however, has not affected outcomes in ICU patients in two studies [5,6]. We therefore suggest that further studies using oral chlorhexidine in ICU patients should be conducted using higher concentrations (2%) to test the most appropriate frequency of use, since oral cleansing is a nursing-driven intervention and clinical trials with chlorhexidine are yet to demonstrate a mortality benefit.

Continuous Aspiration of Subglottic Secretions in the Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery

Aspiration of endotracheal secretions is a major step in the prevention of ventilator-associated pneumonia (VAP). We compared conventional and continuous aspiration of subglottic secretions (CASS) procedures in ventilated patients after major heart surgery (MHS). Randomized comparison during a 2-year period. A total of 714 patients were randomized (24 patients were excluded from the study; 359 CASS patients; 331 control subjects). The results for CASS patients and control subjects (per protocol and intention-to-treat analysis) were as follows: VAP incidence, 3.6% vs 5.3% (p = 0.2) and 3.8% vs 5.1%, respectively; incidence density, 17.9 vs 27.6 episodes per 1,000 days of mechanical ventilation (MV) [p = 0.18] and 18.9 vs 28.7 episodes per 1,000 days of MV, respectively; hospital antibiotic use in daily defined doses (DDDs), 1,213 vs 1,932 (p < 0.001) and 1,392 vs 1,932, respectively (p < 0.001). In patients who had received mechanical ventilation for > 48 h, the comparisons of CASS patients and control subjects were as follows: VAP incidence, 26.7% vs 47.5% (p = 0.04), respectively; incidence density, 31.5 vs 51.6 episodes per 1,000 days of MV, respectively (p = 0.03); median length of ICU stay, 7 vs 16.5 days (p = 0.01), respectively; hospital antibiotic use, 1,206 vs 1,877 DDD (p < 0.001), respectively; Clostridium difficile-associated diarrhea, 6.7% vs 12.5% (p = 0.3), respectively; and overall mortality rate, 44.4% vs 52.5% (p = 0.3), respectively. Reintubation increased the risk of VAP (relative risk [RR], 6.07; 95% confidence interval [CI], 2.20 to 16.60; p < 0.001), while CASS was the only significant protective factor (RR, 0.40; 95% CI, 0.16 to 0.99; p = 0.04). No complications related to CASS were observed. The cost of the CASS tube was 9 vs 1.5 euro for the conventional tube. CASS is a safe procedure that reduces the use of antimicrobial agents in the overall population and the incidence of VAP in patients who are at risk. CASS use should be encouraged, at least in patients undergoing MHS.

Ventilator-Associated Pneumonia

Ventilator-Associated Pneumonia

The closed tracheal suction catheter: 24 hour or 48 hour change?

Closed suction catheters (CSC) for removal of bronchial secretions in intubated patients have been used in intensive care units (ICU) for many years. Manufacturers still recommend daily changes of the catheter in order to reduce the incidence of ventilator associated pneumonia (VAP). There is, however, a lack of clinical evidence to support this recommendation. The objective of this study was therefore to compare the incidence of VAP in patients who receive either 24 hourly or 48 hourly changes of the CSC. Eligible patients were randomised to one of the two groups to receive either a 24 hourly change (n=53) or a 48 hourly change (n=48) of the CSC. Sputum specimens were sent second daily for quantitative culture. Chest x-rays (CXR) and white blood cell counts were attended daily. A VAP was diagnosed according to previously established criteria. A second set of modified criteria were also used to conduct a further analysis of the results. Of the 158 patients randomised, 101 completed the study. These patients had a mean age of 65 years and a mean APACHE II score of 28.2 in the first 24 hours of the study. The average duration in the trial was 10 days. The two groups were comparable in terms of demographic features. There were no reported cases of VAP in either group using the criteria originally selected in the study design. Using a modified criteria to diagnose VAP there were 10 (19%) patients with VAP in the 24 hour group and 13 (27%) in the 48 hour group. The incidence of VAP between the two groups was not statistically different (p=0.35). To conclude, there was no difference in the incidence of VAP between the two groups studied. Based on previous studies conducted by Quirke 1 and Kollef 2 and the experience of our study we have changed our clinical practice to a 48 hour change of the CSC. We would, however, suggest further study or a meta-analysis of the available literature before a recommendation is made.

A Randomized Clinical Trial of Intermittent Subglottic Secretion Drainage in Patients Receiving Mechanical Ventilation

To study the effect of subglottic secretions drainage on the incidence of ventilator-associated pneumonia (VAP) in patients receiving mechanical ventilation. A randomized clinical trial. A 12-bed general ICU. One hundred fifty patients with an expected duration of mechanical ventilation > 72 h were enrolled in the study. Patients were randomly assigned to receive either an endotracheal tube for intermittent subglottic secretions drainage or a standard endotracheal tube. Incidence of VAP, duration of mechanical ventilation, length of ICU stay, length of hospital stay, and mortality. Seventy-five patients were randomized to subglottic secretion drainage, and 75 patients were randomized to the control group. The two groups were similar at the time of randomization with respect to demographic characteristics and severity of illness. VAP was seen in 3 patients (4%) receiving suction secretion drainage and in 12 patients (16%) in the control group (relative risk, 0.22; 95% confidence interval, 0.06 to 0.81; p = 0.014). The other outcome measures were not significantly different between the two groups. Intermittent subglottic secretion drainage reduces the incidence of VAP in patients receiving mechanical ventilation.