Ventilator-associated Pneumonia Infections Research Articles

Analysis of ventilator-associated pneumonia infection route by genome macrorestriction-pulsed-field gel electrophoresis and its prevention with combined nursing strategies.

The aim of the present study was to explore the infection route of ventilator-associated pneumonia (VAP) and assess the effectiveness of a combined nursing strategy to prevent VAP in intensive care units. Bacteria from the gastric juice and drainage from the hypolarynx and lower respiratory tracts of patients with VAP were analyzed using genome macrorestriction-pulsed-field gel electrophoresis (GM-PFGE). A total of 124 patients with tracheal intubation were placed in the intervention group and were treated with a combined nursing strategy, comprising mosapride (gastric motility stimulant) administration and semi-reclining positioning. A total of 112 intubated patients were placed in the control group and received routine nursing care. The incidence rate of VAP, days of ventilation and mortality rate of patients were compared between the two groups. The GM-PFGE fingerprinting results of three strains of Pseudomonas aeruginosa from the gastric juice, subglottic secretion drainage and drainage of the lower respiratory tract in patients with VAP were similar across groups. The number of days spent on a ventilator by patients in the intervention group (7.37±5.32 days) was lower compared with that by patients in the control group (12.34±4.98 days) (P<0.05). The incidence rate of VAP was reduced from 40.81 to 21.25% following intervention with the combined nursing strategy (P<0.05); furthermore, the mortality rate of intubated patients in the intervention group was 29.46%, a significant reduction compared with the 41.94% mortality rate observed in the control group (P<0.05). Gastroesophageal reflux (GER) was confirmed as one of the infection routes for VAP. The combined nursing strategy of gastric motility stimulant administration and the adoption of a semi-reclining position was effective in preventing VAP by reducing the occurrence of GER.

Emerging and Resistant Infections

The lungs are a major target for infection and a key battleground in the fight against the development of antimicrobial drug-resistant pathogens. Ventilator-associated pneumonia (VAP) is associated with mortality rates of 24-50%. The optimal duration of antibiotic therapy against VAP is unknown, but prolonged courses are associated with the emergence of bacterial resistance. De-escalation strategies in which treatment is discontinued based on signs of clinical resolution, fixed durations of therapy (generally 7-8 d), or serum procalcitonin responses have been shown to decrease antibiotic consumption. Outcomes are comparable to longer treatment courses, with the possible exception of VAP due to nonfermenting, gram-negative bacilli such as Pseudomonas aeruginosa. Staphylococcus aureus is a leading cause of VAP and other infections. Outcomes after S. aureus infection are shaped by the interplay between environmental, bacterial, and host genetic factors. It is increasingly clear that mechanisms of pathogenesis vary in different types of S. aureus infections. Genome-scale studies of S. aureus strains, host responses, and host genetics are redefining our understanding of the pathogenic mechanisms underlying VAP. Genome-sequencing technologies are also revolutionizing our understanding of the molecular epidemiology, evolution, and transmission of influenza. Deep sequencing using next-generation technology platforms is defining the remarkable genetic diversity of influenza strains within infected hosts. Investigators have demonstrated that antiviral drug-resistant influenza may be present prior to the initiation of treatment. Moreover, drug-resistant minor variant influenza strains can be transmitted from person to person in the absence of selection pressure. Studies of lung infections and the causative pathogens will remain at the cutting edge of clinical and basic medical research.

Ventilator-Associated Pneumonia Bundle

The ventilator-associated pneumonia (VAP) bundle is a focus of many health care institutions. Many hospitals are conducting process-improvement projects in an attempt to improve VAP rates by implementing the bundle. However, this bundle is controversial in the literature, because the evidence supporting the VAP interventions is weak. In addition, definitions used for surveillance are interpreted differently than definitions used for clinical diagnosis. The variance in definitions has led to lower reported VAP rates, which may not be accurate. Because of the variance in definitions, the Centers for Disease Control and Prevention developed a ventilator-associated event algorithm. Health care institutions are under pressure to reduce the VAP infection rate, but correctly identifying VAP can be very challenging. This article reviews the current evidence related to VAP and provides insight into implementing a suggested revision of the care of patients being treated with mechanical ventilation.

Ventilator-Associated Pneumonia: Overdiagnosis and Treatment Are Common in Medical and Surgical Intensive Care Units

Diagnosing ventilator-associated pneumonia (VAP) is difficult, and misdiagnosis can lead to unnecessary and prolonged antibiotic treatment. We sought to quantify and characterize unjustified antimicrobial use for VAP and identify risk factors for continuation of antibiotics in patients without VAP after 3 days. Patients suspected of having VAP were identified in 6 adult intensive care units (ICUs) over 1 year. A multidisciplinary adjudication committee determined whether the ICU team's VAP diagnosis and therapy were justified, using clinical, microbiologic, and radiographic data at diagnosis and on day 3. Outcomes included the proportion of VAP events misdiagnosed as and treated for VAP on days 1 and 3 and risk factors for the continuation of antibiotics in patients without VAP after day 3. Two hundred thirty-one events were identified as possible VAP by the ICUs. On day 1, 135 (58.4%) of them were determined to not have VAP by the committee. Antibiotics were continued for 120 (76%) of 158 events without VAP on day 3. After adjusting for acute physiology and chronic health evaluation II score and requiring vasopressors on day 1, sputum culture collection on day 3 was significantly associated with antibiotic continuation in patients without VAP. Patients without VAP or other infection received 1,183 excess days of antibiotics during the study. Overdiagnosis and treatment of VAP was common in this study and led to 1,183 excess days of antibiotics in patients with no indication for antibiotics. Clinical differences between non-VAP patients who had antibiotics continued or discontinued were minimal, suggesting that clinician preferences and behaviors contribute to unnecessary prescribing.

Is gastric residual volume monitoring in critically ill patients receiving mechanical ventilation an evidence-based practice?

Sir, Nutritional support in intensive care units (ICUs) is widely accepted as an integral part of patient care, when oral food intake is inadequate or not possible; however, feeding often receives lower priority compared with other ICU treatments such as hemodynamic and ventilation control.[1] Nutritional status is an important factor in health maintenance and disease recovery, particularly in critically ill patients during the mechanical ventilation (MV).[2] Many critically ill patients, especially those who require MV, are unable to eat normally; hence, “artificial nutrition” is provided through enteral or parenteral route.[3] Underfeeding and malnutrition are prevalent in critically ill patients receiving invasive MV. It is estimated that the overall incidence of malnutrition in ICU could be as high as 50%.[4] Moreover, more than 35% of ICU patients are reported to be malnourished upon admission to the ICU.[5] Underfeeding in patients receiving MV can decrease regeneration of respiratory epithelium, respiratory muscles strength and therefore, prolong MV.[2] Furthermore, underfeeding and malnutrition in these patients have an adverse effect on all physiological processes. It increases the risk for infection and pulmonary edema, decreases phosphorus levels needed for cellular energy (adenosine triphosphate) production, reduces ventilatory drive and impairs production of surfactant.[6] Although, enteral nutrition (EN) is the preferred method for nutritional support in ICU patients, patients with enteral feeding are at great risk of malnutrition due to insufficient nutritional intake, primarily due to frequent interruptions in enteral feedings.[7] One of the most important factors for frequent interruptions in enteral feeding in these patients is an increased gastric residual volume (GRV).[6] It is believed that in critically ill patients receiving EN, high GRVs may result in aspiration of gastric contents and increase the risk of ventilator-associated pneumonia (VAP).[8] The practice of monitoring GRVs to assess the safety of enteral tube feeding has been a routine part of enteral feeding protocols in the ICUs. However, little scientific evidence indicates that their use, improves patient outcomes.[9] A study done by Reignier et al. found that the absence of GRV monitoring was not inferior to routine performance of this practice in terms of development of VAP or new infections, lengths of ICU and hospital stay, organ failure scores, or mortality rates in mechanically ventilated patients.[10] Furthermore, the result of another study by Poulard et al., have shown that early EN without GRV measuring in mechanically ventilated patients improves the delivery of enteral feeding, without increasing the rate of vomiting or VAP in these patients.[11] They concluded that the routine GRV monitoring of mechanically ventilated patients during EN may be discontinued in most patients.[10,11] Eliminating GRV monitoring from routine part of enteral feeding protocols in the ICUs may have beneficial effects such as improved EN delivery, prevent underfeeding and consequently can decrease the morbidity and mortality rates in critically ill patients. Also, considering that there are several pathogenetic mechanisms associated with VAP removing interventions such as GRV monitoring with no proven beneficial effects, would allow critical care nurses to focus on interventions of proven value.[11] It should be noted that although the importance of adequate nutritional support in critically ill patients is well-established, in recent years, there has been increasing interest in the concept of ‘permissive underfeeding’ that may be associated with clinical benefit in these patients.[12] A study by Krishnan et al. found that a therapeutic window for caloric intake in medical ICU patients (33-65% of caloric intake requirements calculated using the American College of Chest Physicians (ACCP); approximately 16-18 kcal/kg/day) was associated with better outcome compared to highest (>65%) and lowest (0-32%) tertiles of caloric intake in these patients.[13] Moreover, the results of a study by Casaer et al. have been shown that in critically ill patients, high caloric intake by early initiation of parenteral nutrition to supplement EN during the 1st week after ICU admission is associated with worse prognosis.[14] In sum, in the current climate of evidence-based practice, there is a paucity of scientific information to support GRV monitoring as a routine part of enteral feeding protocols in critically ill patients receiving MV. The use of GRVs monitoring is often based on tradition rather than best evidence, which often guides critical care nurses in the managing enteral feeding with unnecessary interruptions of EN delivery. Therefore, it seems that this practice can be removed from the usual care of these patients. Future research in this regard is strongly recommended.

Ventilator-associated pneumonia bundle: reconstruction for best care.

The ventilator-associated pneumonia (VAP) bundle is a focus of many health care institutions. Many hospitals are conducting process-improvement projects in an attempt to improve VAP rates by implementing the bundle. However, this bundle is controversial in the literature, because the evidence supporting the VAP interventions is weak. In addition, definitions used for surveillance are interpreted differently than definitions used for clinical diagnosis. The variance in definitions has led to lower reported VAP rates, which may not be accurate. Because of the variance in definitions, the Centers for Disease Control and Prevention developed a ventilator-associated event algorithm. Health care institutions are under pressure to reduce the VAP infection rate, but correctly identifying VAP can be very challenging. This article reviews the current evidence related to VAP and provides insight into implementing a suggested revision of the care of patients being treated with mechanical ventilation.

English

AIM AND OBJECTIVES : The aim and objectives of the study is to know the etiological profile and infection rate of ventilator associated pneumonia(VAP) in ICU over one year period. MATERIALS AND METHODS : A hospital based study was carried out in the ICU in ESICMC & PGIMSR Bangalore. This study was conducted from October 2011 to August 2012. The study was carried out amongst inpatients admitted to ICU and who were on ventilator.VAP was defined according to CDC criteria &endotracheal aspirates were collected from eligible patients on ventilator. Identification of pathogens were performed as per guidelines. The data was analysed for determining VAP infection rate. RESULTS: A total of 173 patients were on ventilator in ICU. Among them 57 developed ventilator Associated pneumonia. VAP infection rate was 23%. Acinetobacter baumannii& Pseudomonas aeruginosa were commonest in VAP. The bacterial profile was found to be Acinetobacter baumannii 28 ( 49% ),Pseudomonas aeruginosa 13 ( 23% ),Klebsiella pneumonia 9( 16% ), Escherichia coli 9 ( 16% ) Staphylococcus aureus(MSSA) 2 ( 3.5% ) Enterobacter aerogenes 1 ( 1.75% ). CONCLUSION : The following conclusions were reached 1. VAP infection rate was 23%. 2. A. baumannii &Pseudomonas aeruginosa were predominant organisms.

Lung Abscess in a Patient With VAP: A Rare Case of Lung Infection Complicated by Two Pathogens

Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring in a patient after intubation with an endotracheal tube or tracheostomy tube lasting for 48 hours or more. We describe a case of 75-year-old male who initially presented with pneumonia of the right basis with accompanying plevritis. The patient was intubated and his condition was complicated with a VAP infection while he developed a lung abscess. The antibiotic therapy was based on susceptibility bronchial secretions isolated acinetobacter baumannii and klebsiella pneumoniae; these pathogens were also isolated from the drained abscess. The patient was discharged in good health. The interest of this case is recommended in the existence of two responsible pathogens, the paucity of the development of lung abscess in a patient with VAP, and the successful treatment of the patient with the combination of controlled drainage of the abscess and appropriate antibiotic therapy.

P217: Invasive device associated infection rate from 2005 to 2012 in medical intensive care unit at a university hospital in Turkey

Invasive Device Associated Infection (IDAI) rate in healthcare facilities is one of the important quality indicators. IDAI rate should be monitored and necessary precautions should be implemented. Surveillance for IDAI has been started in 2001 at Hacettepe University (H.U.) intensive care units (ICU). When compared the year 2001 to 2005 surveillance results with other reports it was seen as higher than developed countries. In 2006 Ventilator-associated pneumonia (VAP) rate was doubled than 90 percentiles therefore a several interventions were conducted to decrease VAP and Central Line-Associated Bloodstream Infection (CLABSI) rate in all ICUs since 2007.

Microbial Profile of Early and Late Onset Ventilator Associated Pneumonia in The Intensive Care Unit of A Tertiary Care Hospital in Bangalore, India

Ventilator-associated pneumonia (VAP), an important form of hospital-acquired pneumonia (HAP), specifically refers to pneumonia developing in a patient on mechanical ventilator for more than 48 h after intubation or tracheostomy. Despite the advancements in antimicrobial regimes, VAP continues to be an important cause of morbidity and mortality. VAP requires a rapid diagnosis and initiation of appropriate antibiotic treatment, as there is adverse effect of inadequate antibiotic treatment on patients' prognosis and the emergence of multidrug-resistant (MDR) pathogens. The present study was undertaken to assess the etiological agents of early-onset and late-onset VAP and to know their sensitivity pattern. VAP data over a period of 12 months (February 2012 -February 2013) in a tertiary care ICU was retrospectively analysed. The patients were stratified by age, sex, duration of VAP (Early/Late onset) and the identified pathogens with their sensitivity pattern. Incidence of VAP was found to be 35.14%, out of which 44.23% had early-onset (<4 days MV) VAP and 55.77% had late-onset (>4 days MV) VAP. The most common organisms isolated in early onset and late onset VAP was Pseudomonas aeruginosa, E.coli and Acinetobacter baumanii. All enterobacteriaceal isolates were extended spectrum beta lactamase (ESBL) producing organisms and all Staphylococcus aureus isolates except one were methicillin resistant. The incidence of Multidrug resistant (MDR) Pseudomonas aeruginosa and Acinetobacter were 40% and 37.5% respectively. Due to the increasing incidence of multidrug-resistant organisms in our ICU, early and correct diagnosis of VAP is an urgent challenge for an optimal antibiotic treatment and cure. Hence, knowing the local microbial flora causing VAP and effective infection control practices are essential to improve clinical outcomes.

Prevention and care of ventilator-associated pneumonia in critically ill patients

Ventilator-associated pneumonia (VAP) is a hospital-acquired pneumonia that occurs in patients usually 48 hours or more after mechanical ventilator intubation. VAP is the most common nosocomial infection in critically ill patients. Mechanical ventilators are critical oxygenation and ventilation systems for patients. However, there is a close relationship among self-use efficacy, system settings, and VAP infection rate. VAP not only results in higher mortality, longer hospital stays, and higher medical costs, but also negatively affects patient outcomes and medical care quality. The purpose of this article was to provide reference information on VAP risk factors and prevention measures.

Investigating hospital heterogeneity with a multi-state frailty model: application to nosocomial pneumonia disease in intensive care units

BackgroundMultistate models have become increasingly useful to study the evolution of a patient’s state over time in intensive care units ICU (e.g. admission, infections, alive discharge or death in ICU). In addition, in critically-ill patients, data come from different ICUs, and because observations are clustered into groups (or units), the observed outcomes cannot be considered as independent. Thus a flexible multi-state model with random effects is needed to obtain valid outcome estimates.MethodsWe show how a simple multi-state frailty model can be used to study semi-competing risks while fully taking into account the clustering (in ICU) of the data and the longitudinal aspects of the data, including left truncation and right censoring. We suggest the use of independent frailty models or joint frailty models for the analysis of transition intensities. Two distinct models which differ in the definition of time t in the transition functions have been studied: semi-Markov models where the transitions depend on the waiting times and nonhomogenous Markov models where the transitions depend on the time since inclusion in the study. The parameters in the proposed multi-state model may conveniently be computed using a semi-parametric or parametric approach with an existing R package FrailtyPack for frailty models. The likelihood cross-validation criterion is proposed to guide the choice of a better fitting model.ResultsWe illustrate the use of our approach though the analysis of nosocomial infections (ventilator-associated pneumonia infections: VAP) in ICU, with “alive discharge” and “death” in ICU as other endpoints. We show that the analysis of dependent survival data using a multi-state model without frailty terms may underestimate the variance of regression coefficients specific to each group, leading to incorrect inferences. Some factors are wrongly significantly associated based on the model without frailty terms. This result is confirmed by a short simulation study. We also present individual predictions of VAP underlining the usefulness of dynamic prognostic tools that can take into account the clustering of observations.ConclusionsThe use of multistate frailty models allows the analysis of very complex data. Such models could help improve the estimation of the impact of proposed prognostic features on each transition in a multi-centre study. We suggest a method and software that give accurate estimates and enables inference for any parameter or predictive quantity of interest.

Investigation and analysis of nosocomial infection in neonates

To investigate the incidence of nosocomial infections of newborn infants in neonates and to explore the risk factors and strategies of infection control. There were 433 confirmed cases of nosocomial infection in the neonatal ward of the authors' hospital from January 2007 to December 2009. Their data of epidemiological and clinical characteristics, results of etiological examinations and antibiotic resistance were retrospectively analyzed. During the study, the number of hospitalizations were 6437. Nosocomial infection occurred in 433 patients 513 times. The overall nosocomial infection rate was 6.82%. The overall hospitalization days were 73 663 and nosocomial infection patient-day rates were 6.96‰. The VAP infection rate was 28.7‰. The CRBSI rate was 3.5‰. Gestational age (OR = 1.049), mechanical ventilation (OR = 1.810), umbilical vein catheter (OR = 1.106), hospitalization days (OR = 1.081), premature rupture of membrane (OR = 1.433) were the risk factors for the development of nosocomial infection. There were 197 (38.4%) cases of pneumonia, which was the most common nosocomial infection in Neonatal Ward. There were 129 cases of ventilator-associated pneumonia (VAP), which accounts for 65.5% of pneumonia and 24.4% of cases treated with ventilator. The next was sepsis, 124 cases (24.2%) and 64 cases of diarrheal disease (12.7%). One hundred and eighty two (54.4%) strains of isolates were Gram-negative bacteria, which accounted for the highest proportion. The predominant pathogens of Gram-negative bacteria were Klebsiella pneumoniae (19.6%), followed by Acinetobacter baumannii (8.1%), Pseudomonas aeruginosa (7.2%), Stenotrophomonas maltophilia (4.8%) and Escherichia coli (4.8%). The isolation rates of Klebsiella pneumoniae and Escherichia coli with positive extended-spectrum beta-lactamases (ESBLs) were 91.4% and 75%, respectively. Those two bacteria were universally resistant to cephalosporins. The rate of resistance to imipenem of Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa were 1.5%, 11.1% and 41.7%. The isolation rates of methicillin-resistant Staphylococcus aureus and methicillin-resistant coagulase-negative Staphylococcus were 28.6% and 95.5%. It is important to identify the high risk factors for nosocomial infections in newborn infants. To shorten time for mechanical ventilation and hospitalization days, removal of the central venous catheter as early as possible would be conducive to reducing the morbidity of nosocomial infection. The main pathogens were Gram-negative bacteria. The multidrug resistance of Enterobacteriaceae and Non-fermenters is serious.

Improving Safety Culture Results in Rhode Island ICUs: Lessons Learned from the Development of Action-Oriented Plans

The Rhode Island (RI) Intensive Care Unit (ICU) Collaborative was designed to improve patient safety and clinical outcomes in adult ICUs through a unit-based patient safety program and evidenced-based practices. Few studies have shown how to draw on a strong safety culture to improve clinical outcomes. A study was conducted to (1) examine the impact of a Safety Attitudes Questionnaire Action Plan (SAQAP) on the 2008 Safety Attitudes Questionnaire (SAQ) and (2) determine the impact of an SAQAP on ICU central line-associated blood stream infections (CLABSIs) and ventilator-associated pneumonia (VAP) rates. The SAQ was administered at 23 ICUs in 11 hospitals in fall 2007 and 2008. Units were surveyed as to whether they completed an SAQAP on the basis of 2007 SAQ results. Annual rates of infection were submitted as unadjusted monthly CLABSI infections per 1,000 line days and VAP infections per 1,000 ventilator days for 2007 and 2008. SAQAPs were completed on 9 (39%) of the 23 units. Units that developed SAQAPs demonstrated higher improvement rates in all domains of the SAQ except working conditions. Improvements were close to statistical significance for teamwork climate (+18.4% in SAQAP units versus -6.4%, p = .07) and job satisfaction (+25.9% increase in SAQAP units versus +7.3%, p = .07). Units with SAQAPs decreased the CLABSI rates by 10.2% in 2008 compared with 2007, while those without SAQAP had a 2.2% decrease in rates (p = .59). Similarly, VAP rates decreased by 15.2% in SAQAP units, while VAP rates increased by 4.8% in units without SAQAP (p = .39). Teams that developed SAQAPs improved their unit culture and clinical outcomes. An active, targeted intervention in culture can translate into improved outcomes for patients.

Pharmacokinetic and pharmacodynamic evaluation of tigecycline

Introduction: As the spread of multidrug-resistant (MDR) and extensive drug-resistant (XDR) organisms constitutes a real threat for patients, new antimicrobials are needed. Tigecycline, the first-in-class glycylcycline, possesses an extended spectrum of antimicrobial activity including MDR and XDR organisms, which holds promise as a treatment option beyond currently approved indications and deserves expanded evaluation of its pharmacokinetics/pharmacodynamics (PK/PD).Areas covered: This review highlights the areas where our knowledge on PK/PD of tigecycline has been both strengthened and questioned during the recent years. New information has become available on the PK of tigecycline in patients with complicated skin and skin structure infections, complicated intra-abdominal infection, community- and nosocomial-acquired pneumonia. Human PD data from clinical trials linking tigecycline drug exposure to clinical, microbiological and toxicological outcomes are also of great interest.Expert opinion: Tigecycline remains one of our last resorts against MDR pathogens; its clear role has to be re-defined through intense PK/PD applications; dose escalation and exploration of combinations with other antibiotics seem to be the first step towards an expansion of its currently approved indications. The lung remains the most controversial and challenging site regarding the PK/PD standpoint due to the predominance of Acinetobacter baumannii and carbapenemase-producing Klebsiella pneumoniae among ventilator-associated pneumonia infections, for which tigecycline is mostly used off-label.

Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle

Ventilator-associated pneumonia (VAP) increases in-hospital mortality of ventilated patients to 46%, compared with 32% for ventilated patients who do not develop VAP. In addition, VAP prolongs time spent on the ventilator, length of intensive care unit (ICU) stay, and length of hospital stay. In this study, we implemented VAP bundle to decrease the rate of VAP infection. This is a pre- and postintervention trial beginning in 2006 to decrease the rate of VAP in adult ICUs after initiation of the Institute for Healthcare Improvement (IHI) VAP bundle compared with the VAP rate for the preceding 12 months. The study was conducted at a private general hospital in Saudi Arabia. The study included all adult patients who were on mechanical ventilation from 2006 to 2008. An interdisciplinary performance improvement team was formed. The team implemented an evidence-based VAP bundle adopted from the IHI. The implementation of the VAP prevention bundle resulted in the reduction of VAP rates from a mean of 9.3 cases per 1000 ventilator-days in fiscal year 2006 to 2.3 cases per 1000 ventilator-days in 2007 and to 2.2 in 2008 (P < .001). It is estimated that each VAP case increases the hospital length of stay attributable by 10 days and the mean hospital cost by $40,000. Thus, the potential decrease in hospital cost is $780,000 annually. Implementing the IHI VAP bundle significantly resulted in the reduction of the VAP rate with potential great cost avoidance.

Impact of active surveillance on meticillin-resistant Staphylococcus aureus transmission and hospital resource utilisation

The utility of active surveillance cultures (ASCs) for meticillin-resistant Staphylococcus aureus (MRSA) has been a controversial aspect of infection prevention. This prospective cohort study analyses the effect of ASCs for MRSA on hospital-acquired infections in a tertiary care hospital (hospital 1) and a community-based hospital (hospital 2). Both hospitals have high MRSA prevalence and are part of a large healthcare system in southeastern Michigan. Hospital-acquired infections in the intensive care unit (ICU) and in the rest of the hospital were compared before and after the implementation of ASCs in the ICUs. Patients in hospital 1 with evidence of MRSA colonisation from ASCs were placed in contact isolation during their stay in the ICU; patients from hospital 2 remained in contact isolation throughout their hospital stay. Prevalence of MRSA colonisation on admission to the ICU was 23% and 13% in hospitals 1 and 2, respectively. Average incidence of new colonisation during the study period was 1.85 per 1000 patient-days and 3.47 per 1000 patient-days in hospitals 1 and 2, respectively. A decrease in ventilator-associated pneumonia (VAP) occurred in both hospitals, whereas decrease in hospital-wide nosocomial MRSA infection was demonstrated only in hospital 2. We conclude that, in addition to standard infection prevention initiatives, ASC with contact precautions can be effective in reducing the incidence of VAP and nosocomial MRSA infection in healthcare communities with endemic MRSA.

Ventilator-associated nosocomial pneumonia in intensive care units in Malaysia

The outcome indicator of nosocomial infection (NI) in the intensive care unit (ICU) is used to benchmark the quality of patient care in Malaysia. We conducted a three-year prospective study on the incidences of ventilator-associated pneumonia (VAP), risk factors, and patterns of the microorganisms isolated in three ICUs. A follow-up in prospective cohort surveillance was conducted on patients admitted to an adult medical-surgical ICU of a university hospital and two governmental hospitals in Malaysia from October 2003 to December 2006. VAP was detected using CDC criteria which included clinical manifestation and confirmed endotracheal secretion culture results. In total, 215 patients (2,306 patient-days) were enrolled into the study. The incidence of ICU-acquired device-related NI was 29.3 % (n = 63). The device-related VAP infection rate was 27.0 % (n = 58), with a mechanical ventilator utilization rate of 88.7%. The death rate due to all ICU-acquired NI including sepsis was 6.5%. The most common causative pathogen was Klebsiella pneumoniae (n = 27). Multivariate analysis using Cox regression showed that the risk factors identified were aspiration pneumonia (HR = 4.09; 95% CI = 1.24, 13.51; P = 0.021), cancer (HR = 2.51; 95% CI = 1.27, 4.97; P = 0.008), leucocytosis (HR=3.43; 95% CI= 1.60, 7.37; P=0.002) and duration of mechanical ventilation (HR=1.04; 95% CI = 1.00, 1.08; P = 0.030). Age, gender and race were not identified as risk factors in the multivariable analysis performed. The incidence of VAP was comparable to that found in the National Nosocomial Infection Surveillance (NNIS) System report of June 1998. The incidence of VAP was considered high for the three hospitals studied.

The Impact of a Simple, Low-cost Oral Care Protocol on Ventilator-associated Pneumonia Rates in a Surgical Intensive Care Unit

The purpose of this study was to determine the effects of a simple low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. Preintervention and postintervention observational study. Twenty-four bed surgical/trauma/burn intensive care units in an urban university hospital. All mechanically ventilated patients that were admitted to the intensive care unit between June 1, 2004 and May 31, 2005. An oral care protocol to assist in prevention of bacterial growth of plaque by cleaning the patients' teeth with sodium monoflurophosphate 0.7% paste and brush, rinsing with tap water, and subsequent application of a 0.12% chlorhexidine gluconate chemical solution done twice daily at 12-hour intervals. During the preintervention period from June 1, 2003 to May 31, 2004, there were 24 infections in 4606 ventilator days (rate = 5.2 infections per 1000 ventilator days). After the institution of the oral care protocol, there were 10 infections in 4158 ventilator days, resulting in a lower rate of 2.4 infections per 1000 ventilator days. This 46% reduction in ventilator-associated pneumonia was statistically significant (P = .04). Staff compliance with the oral care protocol during the 12-month period was also monitored biweekly and averaged 81%. The total cost of the oral care protocol was US$2187.49. There were 14 fewer cases of ventilator-associated pneumonia, which led to a decrease in cost of US$140 000 to US$560 000 based on the estimated cost per ventilator-associated pneumonia infection of US$10 000 to US$40 000. There was an overall reduction in ventilator-associated pneumonia without a change to the gram-negative or gram-positive microorganism profile. The implementation of a simple, low-cost oral care protocol in the surgical intensive care unit led to a significantly decreased risk of acquiring ventilator-associated pneumonia.

The Business Case for Preventing Ventilator-Associated Pneumonia in Pediatric Intensive Care Unit Patients

A retrospective matched (1:1) case-control study was conducted to compare the financial impact and costs attributable to ventilator-associated pneumonia (VAP) in a 25-bed pediatric intensive care unit (PICU) in a 475-bed quaternary-care pediatric hospital from the perspective of multiple stakeholders, including the hospital and payors. For PICU patients with VAP from January 1 2005, to December 31, 2005, 13 patients were matched to 13 control patients by age, sex, severity of illness, primary diagnosis, underlying illness, surgical procedures, and duration of mechanical ventilation. The mean hospital length of stay (LOS) for VAP patients was 26.5 +/- 13.1 days compared with 17.8 +/- 4.7 days for non-VAP patients (p = .032). The hospital LOS attributable to VAP was 8.7 days. The mean hospital costs for VAP patients was $156,110 +/- $80,688 compared with $104,953 +/- $59,191 for non-VAP patients (p = 0.026). The attributable VAP costs were $51,157. After implementation of the VAP prevention bundle, VAP rates decreased from 7.8 cases per 1,000 ventilator days in fiscal year (FY) 2005 to 0.5 cases per 1,000 ventilator days in FY 2007 (VAP infections: 24 in FY 2005, 9 in FY 2006, 2 in FY 2007; p < 0.001). This reduced hospital days by 400, reduced unreimbursed cost of care by $442,789, reduced hospital costs by $2,353,222, and reduced cost to payors by $2,653,710 for FY 2006 and FY 2007 combined. This study provides the first demonstration of significant, sustained reductions in pediatric VAP rates following the implementation of the VAP prevention bundle and the first business case analysis of this pediatric-specific intervention as described from the perspective of multiple stakeholders. A return on investment may speed health care organizations' investment in patient safety and quality improvement.