Lower Incidence Of Ventilator-associated Pneumonia Research Articles

Compliance to ventilator care bundles and its association with ventilator-associated pneumonia

PurposeVentilator care bundles are effective in the prevention of ventilator-associated pneumonia (VAP). However, the compliance of these bundles in intensive care units (ICUs) remains poorly studied. This study investigates the Medical Information Mart for Intensive Care (MIMIC)-IV cohort’s compliance with the Institute for Healthcare Improvement (IHI) bundle and its resulting association with VAP incidence.MethodsThis is a retrospective cohort study of the MIMIC-IV database. Patients with > 48 h of invasive mechanical ventilation (IMV) were included. Diagnosis of VAP was identified with the International Classification of Diseases (ICD)-9 and ICD-10 codes. Compliance rates to the IHI bundle were extracted. The association of the IHI bundle and its individual interventions with VAP incidence was analyzed with univariate and multivariate analysis.Results8270 patients were included, of which 1328 (16.1%) had VAP. 25 patients (0.3%) had full compliance to the IHI bundle. 137 patients (1.7%) received no interventions from the bundle. Gastroprophylaxis had the lowest (2.1%) while head elevation had the highest (89.3%) compliance rates. In patients receiving the IHI bundle, each additional intervention was associated with lower VAP incidence (OR [odds ratio] = 0.906, 95% CI [confidence interval] 0.847–0.969). Appropriate sedation levels (OR = 0.765, 95% CI 0.661–0.885) and the use of heat and moisture exchanger (HME) filters (OR = 0.862, 95% CI 0.745–0.998) were individually associated with reduced VAP incidence, while active humidification was individually associated with increased VAP incidence (OR = 1.139, 95% CI 1.001–1.296).ConclusionThe use of the IHI bundle was associated with a lower incidence of VAP, but compliance with the bundle was poor. Appropriate sedation and HME filters were individually associated with reduced VAP incidence. Better compliance with the IHI bundle may reduce VAP rates in mechanically ventilated patients.Graphical

Effects of diaphragm electrical stimulation in treating respiratory dysfunction on mechanical ventilation after intracerebral hemorrhage: A single-center retrospective study.

Intracerebral hemorrhage (ICH) is a major cause of death and disability worldwide. The benefits of electrical stimulation in the treatment of respiratory dysfunction in patients on mechanical ventilation is unknown. Nevertheless, there is a dearth of evidence-based medical research concerning its clinical efficacy. From January 2019 to January 2023, every enrolled patients experienced respiratory dysfunction after ICH while being supported by mechanical ventilation. A total of 205 eligible patients were enrolled and then allocated into 2 groups: control group and observation group. 133 patients was selected and administered standard treatment as control group. Based on conventional treatment, other 72 patients were administered diaphragm electrical stimulation (DES) treatment. We examined information from current medical records, encompassing all initial data and predictive follow-up data, such as the weaning success rate, occurrence of ventilator-associated pneumonia (VAP), duration of stay in the intensive care unit (ICU) and hospital, expenses related to hospitalization, and mortality within 30 days. The baseline clinical data of the 2 groups did not exhibit any statistically significant disparities (all P > .05). The rate of successful weaning showed a significant increase in the DES group when compared to the control group (P = .025). In patients with respiratory dysfunction due to ICH, treatment with DES resulted in a significant reduction in the duration of invasive ventilation (9.8 ± 2.1 vs 11.2 ± 2.6, P < .01) and total ventilation time (9.8 ± 2.1 vs 11.2 ± 2.6, P < .01). It also led to a decrease in the length of stay in the ICU (15.67 ± 3.76 vs 17.53 ± 4.28, P = .002) and hospitalization cost (11500 vs 13600, P = .001). Additionally, DES treatment resulted in a lower incidence of VAP (73.61% vs 86.46%, P = .022) and improved 30-day mortality (P < .05), without any significant adverse effects. The findings of this research indicate that DESs have a positive impact on enhancing the rate of successful weaning and reducing the incidence of VAP. It decreases the duration of invasive ventilation and total ventilation time while also improving the mortality rate within 30 days. This therapy could offer a fresh alternative for respiratory impairment in patients undergoing mechanical ventilation.

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).&#x0D; Study Design: Retrospective examination of hospital records.&#x0D; Place and Duration of Study: Reanimation Intensive Care Unit, Van Training and Research Hospital, Van, Turkey, between January 2018 and December 2019.&#x0D; 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.&#x0D; 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.&#x0D; Conclusion: CESS treatment was associated with a lower incidence of VAP in patients of the RICU.

Impact of early enteral nutrition on ventilator associated pneumonia in intubated severe trauma patients: A propensity score-matched study.

Early enteral nutrition (EN) is recommended for critically ill patients. However, the impact of early EN on intubated severe trauma patients remains unclear. Severely traumatized adult patients who received invasive mechanical ventilation (MV) for more than 48 h during intensive care unit (ICU) stay at our institution between 2017 and 2022 were retrospectively included. Early EN was defined as EN initiation ≤48 h from ICU admission and late EN >48 h. Propensity score matching (PSM) analysis was used to compare outcomes between the groups. The primary endpoint was the incidence of ventilator-associated pneumonia (VAP). Multivariable logistic regression analysis was performed to identify independent predictors of delayed EN. For final analysis, 337 intubated severe trauma patients were available, including 204 (60.5%) in the early EN group and 133 (39.5%) in the late EN group. After PSM, early EN patients had a lower incidence of VAP (12.9 vs. 25.8%, p = 0.026) and a shorter length of hospital stay (21 vs. 24 days, p = 0.015) compared to late EN patients. There was no demonstrable difference in mortality between the two groups. Abdominal trauma, massive blood transfusion, and serum albumin were identified as independent risk factors for delayed EN. Early EN decreased the VAP rate and reduced the length of hospital stay in invasively ventilated patients with severe trauma. Abdominal injury, massive blood transfusion and low albumin were associated with delayed EN.

A meta-analysis of the effects of probiotics on various parameters in critically ill ventilated individuals.

According to reports, ventilator-associated pneumonia affects critically ill patients more frequently than any other nosocomial infection. Probiotic usage as a prophylactic intervention has shown promising results in numerous studies. We performed a meta-analysis to evaluate the effect of probiotics on different parameters in critically ill ventilated subjects. A systematic literature search up to June 2022 was performed and 5893 critically ill ventilated subjects at the baseline of the studies were identified; 2912 of them were using the probiotics, and there were 2981 controls. Odds ratio (OR) and mean difference (MD) with 95% confidence interval (95% CI) were calculated to assess the effect of probiotics on different parameters in critically ill ventilated subjects using the dichotomous and contentious methods with a random or fixed effects model. The probiotics caused a significantly lower incidence of ventilator-associated pneumonia (OR = 0.52; 95% CI: 0.40-0.68, p < 0.001), shorter duration of mechanical ventilation (MD = -2.22; 95% CI: -3.33--1.11, p < 0.001), shorter intensive care unit (ICU) stay (MD = -2.09; 95% CI: -3.41--0.77, p = 0.002), shorter hospital stay (MD = -2.36; 95% CI: -4.54--0.19, p = 0.03), and lower oropharyngeal colonization (OR = 0.59; 95% CI: 0.36-0.96, p = 0.03) in critically ill ventilated subjects compared with controls. However, probiotic use had no significant difference in terms of diarrhea incidence (OR = 0.74; 95% CI: 0.52-1.07, p = 0.11) and in-hospital mortality (OR = 0.90; 95% CI: 0.79-1.03, p = 0.14) in critically ill ventilated subjects compared with controls. Probiotics caused a significantly lower ventilator-associated pneumonia incidence, shorter duration of mechanical ventilation, shorter ICU and hospital stay, and lower oropharyngeal colonization. However, there was no significant difference in terms of diarrhea incidence and in-hospital mortality in subjects who used probiotics compared with controls. The low sample size of 9 out of 27 researches and the small number of studies in several comparisons requires attention when analyzing the results.

Does the presence of oral health teams influence the incidence of ventilator-associated pneumonia and mortality of patients in intensive care units? Systematic review.

To verify whether oral health teams influence the oral health status, ventilator-associated pneumonia incidence and mortality rate of patients in Intensive Care Units (ICU). Bibliographic searches were performed in PubMed, Scopus, Web of Science, Lilacs, Embase, Livivo, Open Grey, Academic Google, and Cochrane databases. The assessment of the methodological quality and risk of bias of the included studies and a random-effects meta-analysis to summarize relative risk data for ventilator-associated pneumonia (VAP) and mortality were performed. An analysis of the certainty of the evidence was performed for the main outcomes analyzed. Records of 518 studies were analyzed by reading titles and abstracts. Five studies were included according to eligibility criteria. The meta-analysis showed that ICU patients undergoing dental care by an oral health team had a lower incidence of VAP (OR=0.33; 95% CI: 014-0.76) but did not lower mortality rates (OR=0.46 95% CI: 0.16-1.32). The certainty of the evidence was considered very low. Dental care provided by oral health teams in a hospital environment did not influence oral health status or mortality, although it contributed to a reduction in VAP of patients admitted to the ICU.

Early tracheostomy: on the cutting edge, some benefit more than others.

The decision to undergo early tracheostomy in critically ill patients has been the subject of multiple studies in recent years, including several meta-analyses and a large-scale examination of the National in-patient Sampling (NIS) database. The research has focused on different patient populations, and identified common outcomes measures related to ventilation. At the crux of the new research is the decision to undergo an additional invasive procedure, mainly tracheostomy, rather than attempt endotracheal tube ventilation with or without early extubation. Notably, recent research indicates that neurological and SARS-CoV-2 (COVID-19) patients seem to have an exaggerated benefit from early tracheostomy. Recent studies of patients undergoing early tracheostomy have shown decreases in ventilator associated pneumonia, ventilator duration and duration of ICU stay. However, these studies have shown mixed data with respect to mortality and length of hospitalization. Such advantages only become apparent with large-scale examination. Confounding the overall discussion is that the research has focused on heterogeneous groups, including neurosurgical ICU patients, general ICU patients, and most recently, intubated COVID-19 patients. Specific populations such as neurosurgical and COVID-19 patients have clearly defined benefits following early tracheostomy. Although the benefit is less pronounced, there does seem to be an advantage in general ICU patients with regards to ventilator-free days and lower incidence of ventilator-associated pneumonia. In these patients, large-scale examination points to a clear mortality benefit.

Assessment of the Clinical Pulmonary Infection Scores for prediction of ventilator associated pneumonia in patients with out of hospital cardiac arrest.

Patients suffering out-of-hospital cardiac arrest (OHCA) are at an increased risk of aspiration pneumonitis and development of subsequent aspiration pneumonia. The diagnostic uncertainty in this context can lead to a large proportion receiving broad spectrum antibiotics. This was a three-year, retrospective cohort study of consecutive patients admitted with OHCA. Data were collected in an Australian tertiary centre intensive care unit (ICU) between December 2016-December 2019. We assessed the incidence of Ventilator associated pneumonia (VAP), admission Clinical Pulmonary Infection Scores (CPIS) in patients with OHCA and its' association with VAP at day 3 [1]. We also assessed antibiotics prescribing (timing of initiation and drug choice) and intensive care mortality relative to the day 1 CPIS. Over the three years, 100 patients were admitted with OHCA. The incidence of VAP was 6%. The CPIS on admission was not associated with development of VAP at day 3 (p=0.75) and no significant association was found between choice of antibiotic regimens and VAP incidence. Timing of initiation of antibiotics was associated with VAP (12hrs vs 48hrs, p=0.035) but not the choice of antibiotic (penicillin and cephalosporins vs antipseudomonal antibiotics). CPIS score at day 1 was not associated with ICU mortality in a multivariate analysis. We demonstrated a very low incidence of VAP in OHCA patients in comparison to published studies. In this context, there was no evidence for an association between CPIS score and VAP at day 3. The CPIS may have utility as a decision support tool for targeted antibiotic prescribing in this cohort.

EARLY PROBIOTICS IN PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA AFTER MULTIPLE TRAUMA

Objective: Using probiotics in preventing ventilator-associated pneumonia (VAP) remain controversial due to different intensive care unit (ICU) populations included in such studies. The aim of this study is to evaluate the role of probiotics in prophylaxis of VAP after multiple trauma.&#x0D; Methods: Sixty-five adult multiple trauma patients on mechanical ventilator (expected ≥48 h) after admission to the Critical Care Medicine Department, Alexandria Main University Hospital from June to November 2018. Patients were randomly assigned using computer sheet into two groups; probiotics group (32 patients received one Lacteol Forte® sachet through orogastric/nasogastric tube 3 times daily during their ICU stay) and control group (33 patients received similar regimen of placebo sachets). All patients were followed up and subjected to all possible strategies of the diagnosis of microbiologically confirmed VAP.&#x0D; Results: Sixty-five patients were enrolled with a mean of age (39.48±7.692) years, 80% of them were male. Regarding the incidence of VAP, it was 18.46% of all patients without statistically significant difference between probiotics group (15.63%) and control group (21.21%) (p=0.751).&#x0D; Conclusion: Routine use of early probiotics in mechanically ventilated multiple trauma patients was not associated with lower incidence of VAP, duration of MV, or ICU mortality.

High tidal volume ventilation is associated with ventilator-associated pneumonia in acute cervical spinal cord injury

Context/Objective Pneumonia is the leading cause of death after acute spinal cord injury (SCI). High tidal volume ventilation (HVtV) is used in SCI rehabilitation centers to overcome hypoventilation while weaning patients from the ventilator. Our objective was to determine if HVtV in the acute post-injury period in SCI patients is associated with lower incidence of ventilator-associated pneumonia (VAP) when compared to patients receiving standard tidal volume ventilation. Design Cohort study. Setting Red Duke Trauma Institute, University of Texas Health Science Center at Houston, TX, USA. Participants Adult Acute Cervical SCI Patients, 2011–2018. Interventions HVtV. Outcome measures VAP, ventilator dependence at discharge, in-hospital mortality. Results Of 181 patients, 85 (47%) developed VAP. HVtV was utilized in 22 (12%) patients. Demographics, apart from age, were similar between patients who received HVtV and standard ventilation; patients were younger in the HVtV group. VAP developed in 68% of patients receiving HVtV and in 44% receiving standard tidal volumes (P = 0.06). After adjustment, HVtV was associated with a 1.96 relative risk of VAP development (95% credible interval 1.55–2.17) on Bayesian analysis. These results correlate with a >99% posterior probability that HVtV is associated with increased VAP when compared to standard tidal volumes. HVtV was also associated with increased rates of ventilator dependence. Conclusions While limited by sample size and selection bias, our data revealed an association between HVtV and increased VAP. Further investigation into optimal early ventilation settings is needed for SCI patients, who are at a high risk of VAP.

Oropharyngeal Administration of Mother's Milk Prior to Gavage Feeding in Preterm Infants: A Pilot Randomized Control Trial.

Oropharyngeal administration of mother's colostrum in early days has an immunoprotective effect in preterm infants. Our aim was to study the effect of oropharyngeal administration of mother's milk (OPAMM) on decreasing the incidence of nosocomial sepsis. In a pilot prospective randomized study on preterm (<32weeks gestation and 1500g weight) infants, we compared OPAMM practice (applying 0.2mL of mother's colostrum or milk prior to gavage feeding until full oral feeding is reached) with regular gavage feeding. The primary outcome was incidence of culture-proven nosocomial sepsis. Secondary outcomes included bacterial colonization of the gastrointestinal tract, feeding intolerance, time to reach full feeding, incidence of necrotizing enterocolitis, ventilator-associated pneumonia, duration of respiratory support, incidence of bronchopulmonary dysplasia (BPD), length of hospital stay, and neonatal mortality. The outcomes of 200 neonates (100 in each group) were analyzed. OPAMM practice did not significantly reduce the incidence of culture proven nosocomial sepsis (8% vs 13%, P = 0.35). Infants in the OPAMM group had a significantly lower growth of Klebsiella species in the oropharyngeal pouch, borderline lower incidence of ventilator-associated pneumonia, shorter duration of oxygen therapy, less episodes of feeding intolerance, reached full feeding earlier, and had a shorter length of hospital stay. OPAMM practice did not affect the incidence of necrotizing enterocolitis, BPD, or neonatal mortality. OPAMM prior to gavage feeding does not reduce the incidence of nosocomial sepsis but had beneficial effects on early achievement of feeding, and early hospital discharge in preterm very low-birth-weight infants.

The impact of tracheotomy timing in critically ill patients undergoing mechanical ventilation: A meta-analysis of randomized controlled clinical trials with trial sequential analysis

BackgroundThe optimal timing of tracheotomy in critically ill ventilated patients remains controversial. ObjectivesThe objective of this meta-analysis was to assess tracheotomy timing for critically ill ventilated patients and determine the outcomes’ reliability. MethodsWe searched PubMed, Embase, and the Cochrane Library for randomized controlled trials. ResultsCompared with late tracheotomy, early tracheotomy presented a lower incidence of ventilator-associated pneumonia (VAP), shorter duration of mechanical ventilation (MV), and shorter intensive care unit (ICU) stay. However, trial sequential analysis (TSA), a kind of cumulative meta-analysis, indicated that the evidence was unreliable and inconclusive. ConclusionsThe Findings suggest that early tracheotomy seems to be associated with a lower incidence of VAP, shorter duration of MV, shorter duration of sedation, and shorter ICU stay. However, the apparent benefits revealed in traditional meta-analysis contrast with the post-TSA results. More fully powered, randomized controlled trials focused on the outcomes of tracheotomy are highly warranted.

Extubation in patients undergoing extracorporeal life support.

Extracorporeal life support (ECLS) is a cardiopulmonary support system used for the treatment of severe cardiac and/or respiratory failure. Mortality is high partly because of the severity of the condition that requires support. The use of ECLS is generally associated with heavy sedation. The aim of this study was to demonstrate the feasibility of stopping sedation, allowing extubation of patients supported by ECLS. 196 patients supported by ECLS for a period of 4 years were included. Sedation was stopped as soon as possible to allow extubation. The 44 extubated patients were compared with non-extubated patients. Finally, 24% of patients were not extubated without a determined cause and were compared with extubated patients. The extubated patients had a lower incidence of ventilator-associated pneumonia. In a multivariate analysis, the independent risk factors for death were the duration of ECLS, age and lack of extubation. Stopping sedation and extubation are feasible in selected patients under ECLS. This strategy could be a survival factor.

Gender disparity in ventilator-associated pneumonia following trauma: identifying risk factors for mortality.

Gender alone offers no survival advantage in humans following trauma. However, male gender does predict increased morbidity, specifically ventilator-associated pneumonia (VAP). Previous work has shown that despite lower incidence of VAP, females with VAP have increased mortality. The purposes of this study were to evaluate the impact of VAP and gender on outcome and to determine which characteristics of severe VAP predict mortality in trauma patients. Patients with VAP (≥10 colony-forming units per milliliter in bronchoalveolar lavage) over 8 years were stratified by gender, age, severity of shock, and injury severity. Severe VAP factors were defined as multiple-episode, polymicrobial, multidrug-resistant, nosocomial VAP diagnosed within 7 days of admission (eNVAP), and multiple inadequate empiric antibiotic therapy episodes. Mortality and severe VAP factors were compared using χ analysis. Multivariable logistic regression (MLR) was performed to determine which VAP factors were independent predictors of mortality. A total of 854 patients were identified, 676 men (79%) and 178 women (21%). Despite a higher incidence of VAP among males (3.8% vs. 2.6%, p = 0.001), mortality was higher in females (24% vs. 15%, p = .009). All characteristics of severe VAP were increased in females except multiple episodes (p = 0.15). MLR identified eNVAP as an independent predictor of mortality in females with severe VAP after adjusting for age, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), admission base excess, and 24-hour transfusions (odds ratio, 9.97; p = 0.001). That females develop less VAP but experience increased mortality confirms previous studies. Characteristics of severe VAP are increased in females and may contribute to this observed mortality difference. MLR identified eNVAP as an independent predictor of mortality in females with severe VAP following trauma. Epidemiologic/prognostic study, level III.

Implementazione di un programma di controllo delle infezioni ospedaliere: un'analisi di costo ed efficacia

This study proposes a cost-effectiveness analysis concerning the implementation of a tool to check for Ventilator Associated Pneumonia (VAP) in Intensive Care. VAP is a sub-type of hospitalacquired pneumonia which occurs in people receiving mechanical ventilation. An empirical analysis is performed to estimate the effectiveness of a specific procedure to prevent VAP (i.e. Ventilator Bundle), as well as to evaluate cost savings related to not developing the infection. The relevance of the results thus obtained is not only clinical but also managerial and economic, since a reduction in costs improves the economic performance of hospitals and a lower incidence of VAP improves their reputation on the national market of healthcare services.

Effect of Oral Hygiene and 0.12% Chlorhexidine Gluconate Oral Rinse in Preventing Ventilator-Associated Pneumonia After Cardiovascular Surgery

Ventilator-associated pneumonia (VAP) is a nosocomial infection of multifactorial etiology and has a negative influence on cardiovascular surgery (CVS) outcomes. Determine the effect of toothbrushing plus 0.12% chlorhexidine gluconate oral rinse in preventing VAP after CVS. In a quasi-experimental study, patients undergoing heart surgery were enrolled in a protocol for controlling dental biofilm by proper oral hygiene (toothbrushing) and oral rinses with 0.12% chlorhexidine gluconate (Group 1), and they were compared with a historical control group (Group 2), which included patients who underwent cardiac surgery between 2009 and 2010 and who received regular oral hygiene care. Seventy-two hours before surgery, a dentist provided instruction and supervised oral hygiene with toothbrushing and chlorhexidine oral rinses to patients in Group 1. Each group comprised 150 patients. A lower incidence of VAP (2.7% [95% CI 0.7-7.8] vs 8.7% [95% CI 4.9-14.7], P = .04) and a shorter hospital stay (9 ± 3 d [95% CI 8.5-9.5] vs 10 ± 4 d [95% CI 9.4-10.7], P = .01) were observed in Group 1. No significant differences in all-cause in-hospital death were observed between groups (5.3% vs 4.7%, P > .99). The risk for developing pneumonia after surgery was 3-fold higher in Group 2 (3.9, 95% CI 1.1-14.2). Oral hygiene and mouth rinses with chlorhexidine under supervision of a dentist proved effective in reducing the incidence of VAP.

A comparison of Listerine® and sodium bicarbonate oral cleansing solutions on dental plaque colonisation and incidence of ventilator associated pneumonia in mechanically ventilated patients: A randomised control trial

Effective oral hygiene has been proposed as a key factor in the reduction of dental plaque colonisation and subsequent development of ventilator associated pneumonia (VAP). Listerine(®) oral rinse, while used extensively in dental practice has rarely been tested in mechanically ventilated patients. Sodium bicarbonate as an oral rinse has been more commonly utilised in oral hygiene regimens in intensive care patients. To test the efficacies of the essential oil mouth rinse, Listerine(®) (Pfizer) and sodium bicarbonate in the reduction of dental plaque colonisation with respiratory pathogens and the subsequent development of VAP. The study design was a prospective, single blind randomised comparative study of adult patients mechanically ventilated for at least 4 days. Patients were randomised to Listerine(®) (Pfizer) oral rinse twice daily, sodium bicarbonate oral rinse 2/24 or sterile water 2/24 (control group). All groups received tooth brushing 3 times a day. Dental plaque colonisation (primary outcome) and incidence of ventilator associated pneumonia (secondary outcome) were studied. Three hundred and ninety-eight patients were randomised to either the Listerine group (127), sodium bicarbonate group (133) or the control group (138). Baseline characteristics were similar for all groups. There were no significant differences between the control and study groups in colonisation of dental plaque at Day 4 (p=0.243). Ventilator associated pneumonia was diagnosed in 18 patients. The incidence was, Listerine(®) group 4.7%, sodium bicarbonate group 4.5% and control 4.3% [OR, 0.99; 95% CI, 0.31 to 3.16; p=0.92]. Compared to the control group, Listerine(®) or sodium bicarbonate oral rinses were not more effective in the reduction of colonisation of dental plaque or the incidence of VAP. Given the low incidence of VAP, the common factor of a small, soft toothbrush as part of an oral hygiene regimen suggests possible benefit in mechanically ventilated patients.

Subglottic secretion drainage for preventing ventilator-associated pneumonia

Subglottic secretion drainage (SSD) has been shown to be associated with a lower incidence of ventilator-associated pneumonia (VAP) in a previous meta-analysis. However, a number of randomized controlled trials (RCTs) have been published since then, and so we aimed to conduct an updated meta-analysis. A systematic literature search of Pubmed, Embase, and Cochrane Central Register of Controlled Trials was conducted using specific search terms. Eligible studies were RCTs that compared SSD with standard endotracheal tube care in mechanically ventilated adult patients. Ten RCTs with 2,213 patients were identified. SSD significantly reduced incidence of VAP (relative risk [RR] = 0.56, 95% confidence interval [CI]: 0.45-0.69, p < 0.00001) and early-onset VAP (RR = 0.23, 95% CI: 0.13-0.43, p < 0.00001), shortened ventilation duration by 1.55 days (95% CI: -2.40 to -0.71 days, p = 0.0003), and prolonged time to VAP by 3.90 days (95% CI: 2.56-5.24 days). Subgroup analyses suggested a significant reduction in incidence of VAP when stratified by intermittent (RR = 0.49, 95% CI: 0.34-0.71, p = 0.0001) and continuous SSD (RR = 0.61, 95% CI: 0.46-0.79, p = 0.0003). No significant differences were observed regarding incidence of late-onset VAP, overall mortality, or length of intensive care unit or hospital stay. This updated meta-analysis confirmed that SSD was beneficial in preventing VAP. Furthermore, the effect of SSD on late-onset VAP, comparison between intermittent and continuous SSD, and safety of SSD in mechanically ventilated patients should be evaluated in future RCTs. I, meta-analysis.

Silver‐coated endotracheal tube versus non‐coated endotracheal tube for preventing ventilator‐associated pneumonia among adults: A systematic review of randomized controlled trials

To compare the effects of using silver-coated endotracheal tube (ETT) versus non-coated ETT on the incidence of ventilator-associated pneumonia (VAP) and mortality in adult patients. We searched MEDLINE, the Cochrane Library, EMBASE, and the Chinese Biomedical Literature Database from inception to June 30, 2011. We also retrieved the reference lists of included studies and reviews. Randomized controlled trials (RCTs) comparing silver-coated ETTs versus non-coated ETTs were included. We pooled the results using a random-effect model and conducted subgroup analyses and sensitivity analyses to address the heterogeneity between studies. We identified two eligible RCTs with a total of 1630 participants. The studies were of high quality according to Cochrane Collaboration's tool for assessing risk of bias. Compared with non-coated ETTs, silver-coated ETTs resulted in lower incidence of VAP (RR=0.64, 95% CI 0.43 to 0.96), device-related adverse events (RR=0.53, 95% CI 0.32 to 0.88), and microbiologic burden (≥10,000 CFU/mL: 0.64, 0.48 to 0.86; ≥100,000 CFU/mL: 0.62, 0.43 to 0.89). However, there was no significant difference in total mortality (RR=1.14, 95% CI 0.99 to 1.30). The limited evidence from meta-analysis of two RCTs showed that using silver-coated ETTs reduced the incidence of VAP, microbiologic burden, and device-related adverse events among adult patients. Additional rigorous randomized trials are needed to confirm these findings.

Application of VAP bundles resulting in low incidence of VAP in ICU

Ventilator-associated pneumonia (VAP) is an airways infection that must have developed more than 48 hours after the patient was intubated. Reducing mortality due to ventilator-associated pneumonia requires an organized process that guarantees early recognition of pneumonia and consistent application of the best evidence-based practices. The Ventilator Bundle is a series of interventions developed by IHI related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually.