Ventilator-associated Pneumonia Surveillance Research Articles

Application of ventilator-associated events (VAE) in ventilator-associated pneumonia (VAP) notified in Brazil (IMPACTO MR-PAV): a protocol for a cohort study

IntroductionCertain criteria for ventilator-associated events (VAE) definition might influence the type of an event, its detection rate and consequently the resource expenditure in intensive care unit. The Impact of Infections...

The impact of the COVID-19 pandemic on the trend of ventilator associated pneumonia incidence in a non-COVID-19 dedicated hospital.

Ventilator associated pneumonia (VAP) is one of the most common hospital-acquired infections for intensive care units in China. Since the COVID-19 outbreak, "Lockdown Wuhan" and other infection control strategies had been implemented in China. The impact of the policies on VAP prevention was estimated in a non-COVID-19 dedicated hospital. We analyzed the VAP trends of 6 intensive care units in a non-COVID-19 dedicated hospital from 2018 to 2020 by Joinpoint regression analysis. The information related to infected VAP patients, VAP surveillance were retrieved from an active surveillance system. There was an obvious decrease in the overall admissions and inpatients of ICUs since January 2020. The overall incidence of VAP was 6.1 episodes per 1000 IMV days. The 30-day case fatality was 16.8%. Generally, the utility rate of IMV ranged from 18.2% to 38.9% respectively, raising with the monthly percent change (MPC): 1.5% [95% confidence interval (CI): 0.8%, 2.2%] from January 2018 to February 2020 by Joinpoint regression analysis. A continuous decline with the MPC: -1.9% (95% CI: -3.2%, -0.5%) of VAP incidence was demonstrated. However, this trend varied among the different ICUs. We found no significant difference neither in 30-day case fatality nor pathogens of VAP patients. By Joinpoint regression analysis, we can see February 2020 was an important time point. The surveillance indicators were changed, which influenced the VAP incidence.

Antimicrobial materials for endotracheal tubes: A review on the last two decades of technological progress.

Ventilator-associated pneumonia (VAP) is an unresolved problem in nosocomial settings, remaining consistently associated with a lack of treatment, high mortality, and prolonged hospital stay. The endotracheal tube (ETT) is the major culprit for VAP development owing to its early surface microbial colonization and biofilm formation by multiple pathogens, both critical events for VAP pathogenesis and relapses. To combat this matter, gradual research on antimicrobial ETT surface coating/modification approaches has been made. This review provides an overview of the relevance and implications of the ETT bioburden for VAP pathogenesis and how technological research on antimicrobial materials for ETTs has evolved. Firstly, certain main VAP attributes (definition/categorization; outcomes; economic impact) were outlined, highlighting the issues in defining/diagnosing VAP that often difficult VAP early- and late-onset differentiation, and that generate misinterpretations in VAP surveillance and discrepant outcomes. The central role of the ETT microbial colonization and subsequent biofilm formation as fundamental contributors to VAP pathogenesis was then underscored, in parallel with the uncovering of the polymicrobial ecosystem of VAP-related infections. Secondly, the latest technological developments (reported since 2002) on materials able to endow the ETT surface with active antimicrobial and/or passive antifouling properties were annotated, being further subject to critical scrutiny concerning their potentialities and/or constraints in reducing ETT bioburden and the risk of VAP while retaining/improving the safety of use. Taking those gaps/challenges into consideration, we discussed potential avenues that may assist upcoming advances in the field to tackle VAP rampant rates and improve patient care. STATEMENT OF SIGNIFICANCE: The use of the endotracheal tube (ETT) in patients requiring mechanical ventilation is associated with the development of ventilator-associated pneumonia (VAP). Its rapid surface colonization and biofilm formation are critical events for VAP pathogenesis and relapses. This review provides a comprehensive overview on the relevance/implications of the ETT biofilm in VAP, and on how research on antimicrobial ETT surface coating/modification technology has evolved over the last two decades. Despite significant technological advances, the limited number of gathered reports (46), highlights difficulty in overcoming certain hurdles associated with VAP (e.g., persistent colonization/biofilm formation; mechanical ventilation duration; hospital length of stay; VAP occurrence), which makes this an evolving, complex, and challenging matter. Challenges and opportunities in the field are discussed.

Evaluation of characteristics, clinical relevance and outcome of ventilator associated pneumonia and ventilator associated events algorithm

Background: Surveillance for ventilator-associated pneumonia (VAP) has long been a challenge because of the lack of objective, reliable definitions. Hence, National Healthcare Safety Network (NHSN) has introduced ventilator-associated events (VAEs) as a surveillance definition. While VAE identifies all the possible complications in a mechanically ventilated patient, VAP recognises only the infective complications. There are several retrospective studies reporting no concordance between the occurrence of VAE and VAP. A prospective, observational study in medical intensive care unit (ICU) was conducted over 1 year with the objective of comparing all three tiers of VAE, which are ventilator-associated condition (VAC), infection-related ventilator-associated complication (iVAC) and possible VAP (PVAP), along with VAP in terms of predictive value, characteristics and clinical relevance. Materials and Methods: A prospective cohort study was conducted from July 2018 to June 2019 at PGIMER, Chandigarh, in a 12-bedded medical ICU. All patients with more than 48 h of mechanical ventilation (MV) were included. The demographic data, Acute Physiology and Chronic Health Evaluation-II at 24 h of admission, days of MV, length of ICU stay and outcome of patients were recorded. The patients were screened for both VAP and VAE. Results: Out of a total of 405 patients, 274 patients were included with 3945 patient days and 3330 MV days. The incidence of VAP, VAC, iVAC and PVAP was 6.91, 8.41, 5.41 and 1.50/1000 ventilator days, respectively. Kendall's W-test showed that there was no concordance between VAP and VAE. Conclusion: The study concluded no concordance between cases identified as VAE and VAP.

Development and Implementation of a Ventilator-associated Pneumonia Prevention Oral Care

Background : Ventilator-associated pneumonia (VAP) results in significant increases in both hospital stay and morbidity. A Level I Trauma Center focused attention on VAP prevention following a notable increase over a two-year period. The goal of this project was to implement a new oral care program for vented patients to decrease VAP rates. Methods : Surveillance for VAP was completed for patients at a Level 1 Trauma Center utilizing National Healthcare Safety Network pneumonia definition for critical care patients admitted from 2017 through September 2020. Infection Prevention performed a comprehensive review of ventilated patient care and VAP bundle prevention through staff interviews and shadowing of critical care nursing staff and respiratory therapists. The VAP rate was calculated by the number of VAP/ventilator days x 1000. Results : A comprehensive review of vented patients determined there was variability with oral care practices, including products, number of times oral care occurred per day and oral care documentation. The oral care bundle included (1) increase from Q6 oral care to Q4 oral care for all vented patients, (2) integration and standardization of new oral care products, (3) addition of twice daily chlorhexidine gluconate oral care for seven days post-extubation, (4) Oral Care Road Show entitled “Brush Pneumonia Away” to educate on the importance of oral care and the changes with the process and (5) ability for respiratory therapy to document on VAP bundle prevention including oral care. A 65% decrease in VAP rate occurred between 2018/2019 (9.69) and 2020 (3.31). Conclusions : Implementation of an oral care bundle in a Level I Trauma Center with a significant daily census of critically ventilated patients improved VAP rate. Oral care interventions have been recognized as an effective method in reducing the risk of VAP in critically ill patients.

Retraction to active surveillance of ventilator-associated pneumonia in the intensive care unit and establishment of the risk grading system and effect evaluation.

[This retracts the article DOI: 10.21037/atm.2019.11.25.].

Device associated infections at a trauma surgical center of India: Trend over eight years

BackgroundDevice-associated infections (DAIs) are an important cause of excessive stay and mortality in ICUs. Trauma patients are predisposed to acquire such infections due to various factors. The prevalence of HAIs is underreported from developing nations due to a lack of systematic surveillance. This study reports the rates and outcomes of DAIs at a dedicated Trauma Center in trauma patients and compares the rates with a previous pilot observation. MethodsThe study reports the finding of ongoing surveillance and the use of an indigenous software at a level-1 trauma center in India. Surveillance for ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections was done based on standard definitions. The rates of HAIs and the profile of pathogens isolated from June 2010 to December 2018 were analyzed. ResultsA total of 7485 patients were included in the analysis, amounting to 68,715 patient days. The rates of VAP, CLABSI, and CA-UTI were respectively 12, 9.8 1st 8.5/1000 device days. There was a significant correlation between device days and the propensity to develop infections. Of the 1449 isolates recovered from cases of DAIs, Acinetobacter sp (28.2%) was the most common isolate, followed by Candida sp. A high rate of multi-resistance was observed. ConclusionAutomated surveillance was easy and useful for data entry and analysis. Surveillance data should be used for implementing preventive programs.

Ventilator-associated Events in Children: Controversies and Research Needs.

Ventilator-associated Events in Children: Controversies and Research Needs.

Ventilator-associated pneumonia surveillance using two methods

Ventilator-associated pneumonia surveillance is used as a quality indicator due to concerns that some cases may be preventable and may contribute to mortality. Various surveillance criteria exist for the purposes of national reporting, but a large-scale direct comparison has not been conducted. A prospective cohort study applied two routinely used surveillance criteria for ventilator-associated pneumonia from the European Centre for Disease Control and the American Centers for Disease Control to all patients admitted to two large general intensive care units. Diagnostic rates and concordance amongst diagnostic events were compared. A total of 713 at-risk patients were identified during the study period. The European surveillance algorithm returned a rate of 4.6 cases of ventilator-associated pneumonia per 1000 ventilation days (95% confidence interval 3.1-6.6) and the American surveillance system a rate of 5.4 (3.8-7.5). The concordance between diagnostic events was poor (Cohen's Kappa 0.127 (-0.003 to 0.256)). The algorithms yield similar rates, but the lack of event concordance reveals the absence of inter-algorithm agreement for diagnosing ventilator-associated pneumonia, potentially undermining surveillance as an indicator of care quality.

Active surveillance of ventilator-associated pneumonia in the intensive care unit and establishment of the risk grading system and effect evaluation.

To discuss ventilator-associated pneumonia (VAP) patient's clinical characteristic and related factors in the intensive care unit (ICU), and to establish a risk grading system for VAP patients in the ICU in order to provide a reference for VAP prevention. A total of 1,513 patients in eight ICUs who received mechanical ventilation between June 2015 and June 2018 were randomized and into two groups, with 908 patients in the model group and 605 patients in the verification group. The model group was used to analyze the influencing factors of VAP and establish a risk grading system, while the verification group was used to verify the risk grading system. A receiver operating characteristic (ROC) curve was used to evaluate the predictive effect of the grading system. During the 3-year study period, of the 1,513 total patients, 188 patients were infected with VAP, leading to an incidence rate of 12.43% (188/1,513) and an infection rate of 15.23‰ (188/12,347). ICU length of stay, mechanical ventilation days, frequency of oral care, unused subglottic secretion drainage, tracheotomy, APACHE II score, and combined antibiotics use were risk factors of VAP infection for patients who received mechanical ventilation in the modeling group (P<0.05). In a VAP risk-grading system established based on risk factors, the high, medium and low-grade patients had a statistically significantly different VAP infection rate in the model group, and patients with a high grade had a higher risk of VAP infection. Patients' data in the model and verification groups were used to draw a ROC curve which showed a good predictive effect. This study establishes and verifies the VAP risk grading system for patients who receive mechanical ventilation. It is helpful in high-risk patient surveillance and in reducing and preventing VAP infection.

Using flexible methods to determine risk factors for ventilator-associated pneumonia in the Netherlands.

Seven hospitals participated in the Dutch national surveillance for ventilator-associated pneumonia (VAP) and its risk factors. We analysed time-independent and time-dependent risk factors for VAP using the standard Cox regression and the flexible Weighted Cumulative Effects method (WCE) that evaluates both current and past exposures. The prospective surveillance of intensive care patients aged ≥16 years and ventilated ≥48 hours resulted in the inclusion of 940 primary ventilation periods, comprising 7872 ventilation days. The average VAP incidence density was 10.3/1000 ventilation days. Independent risk factors were age (16–40 years at increased risk: HR 2.42 95% confidence interval 1.07–5.50), COPD (HR 0.19 [0.04–0.78]), current sedation score (higher scores at increased risk), current selective oropharyngeal decontamination (HR 0.19 [0.04–0.91]), jet nebulizer (WCE, decreased risk), intravenous antibiotics for selective decontamination of the digestive tract (ivSDD, WCE, decreased risk), and intravenous antibiotics not for SDD (WCE, decreased risk). The protective effect of ivSDD was afforded for 24 days with a delay of 3 days. For some time-dependent variables, the WCE model was preferable over standard Cox proportional hazard regression. The WCE method can furthermore increase insight into the active time frame and possible delay herein of a time-dependent risk factor.

Comparison of Ventilator-associated Event Surveillance and Conventional Ventilator-associated Pneumonia Surveillance

Comparison of Ventilator-associated Event Surveillance and Conventional Ventilator-associated Pneumonia Surveillance

Bacteriology and antibiotic susceptibility pattern of ventilator-associated pneumonia in a tertiary care hospital

Background: Ventilator-associated pneumonia (VAP) is one of the most important hospital-acquired infections. VAP is pneumonia that develops 48 h or more after patients have been intubated and received mechanical ventilation by means of an endotracheal tube or tracheostomy. VAP is usually suspected when an individual develops a new or progressive infiltrates on chest radiograph, leukocytosis, and purulent tracheobronchial secretions. This is diagnosed based on positive end-expiratory pressure, fraction of inspired oxygen, bacteriological evidence, and signs of pulmonary infection. VAP is considered as one of the leading causes of morbidity and mortality in intensive care units (ICUs). Objectives: The objectives of this study were to assess the common pathogenic bacteria causing VAP and to determine its antibiotic susceptibility pattern. Materials and Methods: This study was conducted on 100 patients with clinical diagnosis of VAP. Bacterial culture was done for patient’s endotracheal aspirates. Antibiotic sensitivity test was done for culture-positive cases by Kirby–Bauer disk diffusion method. Results: A total of 72 patients (72%) showed positive culture. Gram-negative bacilli accounted for 91% of the isolated organisms with Acinetobacter species accounting for 40% followed by Pseudomonas species (26%) and Klebsiella pneumoniae (14%). Majority of the organisms were sensitive to imipenem with Acinetobacter being sensitive in 51% cases, Pseudomonas in 56%, and Klebsiella in 42% cases. Conclusion: Surveillance of VAP in ICUs is required to find out common causative organism and its antibiotic susceptibility to different antibiotics. This type of surveillance study is helpful for formulating antibiotic policy that would be more rational to reduce mortality and morbidity associated with VAP.

Changes in health care-associated infection prevention practices in Japan: Results from 2 national surveys

A national survey conducted in 2012 revealed that the rates of regular use of many evidence-based practices to prevent device-associated infections were low in Japanese hospitals. We conducted a second survey 4 years later to evaluate changes in infection prevention practices. Between July 2016 and January 2017, the instrument used in a survey of Japanese hospitals in 2012 was sent to 1,456 Japanese hospitals. The survey assessed general hospital and infection prevention program characteristics and use of practices specific to preventing catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Independent sample chi-square tests were used to compare prevention practice rates between the first and second surveys. A total of 685/971 (71%) and 940/1,456 (65%) hospitals responded to the first and second surveys, respectively. For CAUTI, only use of bladder ultrasound scanners (11.1%-18.1%; P < .001) increased. For CLABSI, use of chlorhexidine gluconate for insertion site antisepsis (18.5%-41.1%; P < .001), antimicrobial dressing with chlorhexidine (3.4%-7.1%; P = .001), and central line insertion bundle (22.9%-33.0%; P < .001) increased. For VAP, use of semirecumbent positioning of patients (65.0%-72.3%; P = .002), sedation vacation (31.5%-41.6%; P < .001), oscillating/kinetic beds (4.7%-8.6%; P = .002), and a collective VAP prevention bundle (24.8%-34.8%; P < .001) increased. Fewer than 50% of Japanese hospitals reported conducting CAUTI and VAP surveillance. Collaborative approaches and stronger incentives promoting infection prevention efforts may be warranted to further increase use of most evidence-based practices to reduce common health care-associated infections in Japan.

Epidemiological surveillance of Ventilator-Associated Pneumonia in Intensive Care Units of adults in Argentina

Epidemiological surveillance of Ventilator-Associated Pneumonia in Intensive Care Units of adults in Argentina

Impact of the International Nosocomial Infection Control Consortium (INICC)'s multidimensional approach on rates of ventilator-associated pneumonia in intensive care units in 22 hospitals of 14 cities of the Kingdom of Saudi Arabia.

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Approach (IMA) and use of INICC Surveillance Online System (ISOS) on ventilator-associated pneumonia (VAP) rates in Saudi Arabia from September 2013 to February 2017. A multicenter, prospective, before-after surveillance study on 14,961 patients in 37 intensive care units (ICUs) of 22 hospitals. During baseline, we performed outcome surveillance of VAP applying the definitions of the CDC/NHSN. During intervention, we implemented the IMA and the ISOS, which included: (1) a bundle of infection prevention practice interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback on VAP rates and consequences and (6) performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using generalized linear mixed models to estimate the effect of intervention. The baseline rate of 7.84 VAPs per 1000 mechanical-ventilator (MV)-days-with 20,927 MV-days and 164 VAPs-, was reduced to 4.74 VAPs per 1000 MV-days-with 118,929 MV-days and 771 VAPs-, accounting for a 39% rate reduction (IDR 0.61; 95% CI 0.5-0.7; P 0.001). Implementing the IMA was associated with significant reductions in VAP rates in ICUs of Saudi Arabia.

Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on rates of ventilator-associated pneumonia in intensive care units of two hospitals in Kuwait.

To analyse the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach (IMA) on ventilator-associated pneumonia (VAP) rates in three intensive care units (ICUs) from two hospitals in Kuwait City from January 2014 to March 2015. A prospective, before-after study on 2507 adult ICU patients. During baseline, we performed outcome surveillance of VAP applying CDC/NHSN definitions. During intervention, we implemented the IMA through the INICC Surveillance Online System (ISOS), which included: (1) a bundle of infection prevention interventions; (2) education; (3) outcome surveillance; and (4) feedback on VAP rates and consequences. Logistic regression analysis was performed to estimate the effect of the intervention on VAP, controlling for potential bias. During baseline, 1990 mechanical ventilator (MV)-days and 14 VAPs were recorded, accounting for 7.0 VAPs per 1000 MV-days. During intervention, 9786 MV-days and 35 VAPs were recorded, accounting for 3.0 VAPs per 1000 MV-days. The VAP rate was reduced by 57.1% (incidence-density ratio = 0.51; 95% CI = 0.28-0.93; p = 0.042). Logistic regression showed a significant reduction in VAP rate during the intervention phase (OR = 0.39, 95% CI = 0.18-0.83), with 61% effectiveness. Implementing IMA through ISOS was associated with a significant reduction in the VAP rate in Kuwait ICUs.

Impact of the International Nosocomial Infection Control Consortium's multidimensional approach on rates of ventilator-associated pneumonia in 14 intensive care units in 11 hospitals of 5 cities within Argentina

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach (IMA) on ventilator-associated pneumonia (VAP) rates in 11 hospitals within 5 cities of Argentina from January 2014-April 2017. A multicenter, prospective, before-after surveillance study was conducted through the use of International Nosocomial Infection Control Consortium Surveillance Online System. During baseline, we performed outcome surveillance of VAP applying the definitions of the Centers for Disease Control andPrevention's National Healthcare Safety Network. During intervention, we implemented the IMA, which included a bundle of infection prevention practice interventions, education, outcome surveillance, process surveillance, feedback on VAP rates and consequences, and performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention. We recorded 3,940 patients admitted to 14 intensive care units. At baseline, there were 19.9 VAPs per 1,000 mechanical ventilator (MV)-days-with 2,920 MV-days and 58 VAPs, which was reduced during intervention to 9.4 VAPs per 1,000 MV-days-with 9,261 MV-days and 103 VAPs. This accounted for a 52% rate reduction (incidence density rate, 0.48; 95% confidence interval, 0.3-0.7; P .001). Implementing the IMA was associated with significant reductions in VAP rates in intensive care units within Argentina.

Microbial investigations in throat swab and tracheal aspirate specimens are beneficial to predict the corresponding endotracheal tube biofilm flora among intubated neonates with ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is a common nosocomial infection in neonatal intensive care units with high morbidity and mortality. Bacterial biofilm in the endotracheal tube (ET) provides a notable and persistent source of pathogens that may cause VAP, and thus is important for VAP detection. However, during intubation microbial investigations in ET, samples are unavailable due to the infeasibility of collecting ET samples during intubation of neonates. It is therefore of great importance to find alternative sources of samples that can help identify the ET biofilm flora. In the present study, the microbial signatures of throat swabs and tracheal aspirates were compared with ET biofilm samples from VAP neonates using 16S ribosomal RNA gene polymerase chain reaction, denaturing gradient gel electrophoresis (DGGE), cloning and sequencing. Sequences were assigned to phylogenetic species using BLAST. Microbial diversity and richness among the three types of specimens were compared based on their DGGE fingerprints, and taxonomic characteristics based on the BLAST results. The microbial richness and diversity of ET biofilms were similar to tracheal aspirate yet significantly different from throat swab samples (P<0.05). Compared with ET biofilms, the overall constituent ratio of microflora was significantly different in throat swab and tracheal aspirate samples (P<0.05). However tracheal aspirate samples were useful for predicting Staphylococcus sp. in ET biofilms with a sensitivity of 85.7% and a specificity of 83.3%. The sensitivity for the combination of tracheal aspirate and throat swab samples to detect Staphylococcus sp. in ET biofilms was 100%. The detection of Pseudomonas sp. in throat swabs assisted its identification in ET biofilms (sensitivity 33.3% and specificity 100%). The results of the present study suggest that microbial investigations in throat swab and tracheal aspirate samples are beneficial for identifying the ET biofilm flora. There may therefore be clinical applications of using substituent samples to identify pathogens in ET biofilms for VAP surveillance among intubated neonates.

Using Ventilator-Associated Pneumonia Rates as a Health Care Quality Indicator: A Contentious Concept.

Pneumonia is a leading cause of hospital-acquired infections, although reported rates of ventilator-associated pneumonia (VAP) have been declining in recent years. A multifaceted infection prevention approach, using a “ventilator bundle,” has been shown to reduce the frequency of VAP, while improving other patient outcomes. Because of difficulties in defining VAP, the Center for Medicare and Medicaid Service introduced a new streamlined ventilator-associated event (VAE) definition in 2013 for the surveillance of complications in mechanically ventilated patients. VAE measures are increasingly being measured by institutions in the United States in place of VAP rates and as a potential measure of the quality of intensive care unit (ICU) care. However, there is increased recognition that the streamlined definitions identify a different subset of patients than those identified by traditional VAP surveillance and that VAP prevention strategies may not impact all the causes of VAE. Also, VAP and VAE rates may not always reflect the quality of care in a given ICU, especially since patient factors, beyond the control of the hospital, may impact the rates of VAP and VAE. In this review, we discuss the issues related to VAP as a quality measure and the areas of uncertainty related to the new VAE definitions.