Prevention of Ventilator
Associated Pneumonia
Safe Critical Care Project
Vanderbilt-HCA Collaborative
Ventilator Associated Pneumonia (VAP) Key Points • VAP is the 2nd most common nosocomial infection =
15% of all hospital acquired infections
• Incidence = 9% to 70% of patients on ventilators
• Increased ICU stay by several days
• Increased avg. hospital stay 1 to 3 weeks
• Mortality = 13% to 55%
• Added costs of $40,000 - $50,000 per stay
Centers for Disease Control and Prevention, 2003.
Rumbak, M. J. (2000). Strategies for prevention and treatment. Journal of Respiratory Disease,
21 (5), p. 321;
Challenge and Controversy
“There is no doubt that the diagnosis and
management of VAP remains one of the
most controversial and challenging topics
in management of critically ill patients.”
Chan C, Chest 2005;127:425
Changing Views of VAP
• No longer just an “unfortunate” occurrence
• Viewed as medical error
– Institute of Medicine
– Leapfrog Group
• JCAHO – hospitals required to show VAP
prevention/reduction measures
Diagnosing VAP
• VAP is a Nosocomial Pneumonia = Hospital
acquired
• Diagnosis is imprecise and usually based on a
Combination of:
– Clinical factors - fever or hypothermia; change in
secretions; cough; apnea/bradycardia; tachypnea
– Microbiological factors - positive cultures of
blood/sputum/tracheal aspirate/pleural fluids
– CXR factors - new or changing infiltrates
DiagnosingVAP
• Diagnosis of VAP can be a confusing and complicated process.
• In order to clarify the process and help clinicians, the Centers
for Disease Control and Prevention (CDC) published
guidelines for diagnosing VAP in 2003
*Guidelines for Preventing Health-Care--Associated Pneumonia, 2003
* http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
• These guidelines were revised and updated in a joint statement
published by the American Thoracic Society and the Infectious
Diseases Society of America
* Am J Respir Crit Care Med 171:388-416, 2005
Diagnosing VAP
• For this project, we used the revised guidelines
to developed tools to help clinicians with
making the diagnosis.
Am J Respir Crit Care Med 171:388-416, 2005
Bad Bugs: Pathogens in VAP (1)
• Pathogens that cause VAP differ depending on
whether the condition occurs early (less than
96 hours after intubation or admission to ICU)
or late (greater than 96 hours after intubation
or admission to ICU)
Kollef M, Chest 2005;128:3854-62
Bad Bugs: Pathogens in VAP (2)
• Early–Onset Pneumonia (< 96 hours of
intubation or ICU admission)
– Community-acquired
– Pathogens:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Staphylococcus aureus
– Antibiotic-sensitive
Bad Bugs: Pathogens in VAP (3)
• Late-Onset Pneumonia (> 96 hours of
intubation or ICU admission)
– Hospital-acquired
– Pathogens:
•
•
•
•
Pseudomonas aeruginosa
Methicillin resistant Staphylococcus aureus (MRSA)
Acinetobacter
Enterobacter
• Antibiotic-resistant
Kollef M, Chest 2005;128:3854-62
Risk Factors for
Nosocomial Pneumonia
• Major risk factor = mechanical intubation
• Factors that enhance colonization of the oropharynx
&/or stomach:
– Administration of antibiotics
– Admission to ICU
– Underlying chronic lung disease
• Conditions favoring aspiration into the respiratory
tract or reflux from GI tract:
–
–
–
–
–
Supine position
*GERD
NGT placement
*Coma/delirium
Intubation and self-extubation
Immobilization
Surgery of head/neck/thorax/upper abdomen
Risk Factors for
Nosocomial Pneumonia (cont’d)
• Conditions requiring prolonged use of mechanical
ventilatory support with potential exposure to
contaminated respiratory devices &/or contact with
contaminated hands
• Host Factors:
–
–
–
–
Extremes of age
Malnutrition
Immunocompromised
Underlying condition/disease process
Cook D et al, Ann Intern Med 1998;129:433-40
Diagnosing VAP:
using flow diagrams as guides
Four diagrams
• Algorithm #1:
• Algorithm #2:
• Algorithm #3:
• Algorithm #4:
Adolescents and adults
Immunocompromised pt.
Children 1 to <12 years
Infants (<1 year)
Algorithm #2: Diagnosing VAP in Immunocompromised Patients
Algorithm #3: Diagnosing VAP in Children (Age >1 and <13 years)
Algorithm #4: Diagnosing VAP in Infants (Age <1 year old)
VAP Antibiotic Selection
(introductory comments)
• Considerations in making selection
–
–
–
–
Setting (community, NH, hospital)
Suspected organism (GNRs, GPCs)
Host factors (immunosuppression)
Local susceptibility patterns
• Initial empiric and broad; subsequent narrowing
– Concept is to not miss the organism with initial
coverage and then de-escalate when able
Selected references
Centers for Disease Control and Prevention Guidelines for Preventing Healthcare-Associated
Pneumonia, 2003, [http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm]
Cook D et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill
patients. Ann Intern Med 1998 Sep 15;129(6):433-40.
Dodek, P and the Canadian Critical Care Trials Group. Evidence-based clinical practice guideline
for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004 Aug
17;141(4):305-13.
Guidelines for the management of hospital-acquired, ventilator-associated and healthcareassociated pneumonia. Joint statement the American Thoracic Society and the Infectious
Diseases Society of America. Am J Respir Crit Care Med 2005, 171:388-416.
Kollef M, epidemiology and outcomes of healthcare-associated pneumonia: results from a large
US database of culture-positive pneumonia. Chest 2005,128:3854-62.
Langley JM, Bradley JS. Defining pneumonia in critically ill infants and children. Pediatr Crit
Care Med 2005, 6[supplement]:S9-S13.
Rumbak, M. J. Strategies for prevention and treatment. Journal of Respiratory Diseases, 2000,
21(5):321-327.
Ventilator associated Pneumonia
• Next webcast will focus on Ventilator Bundle:
– Interventions to prevent or reduce VAP
– Check lists to help the patient care team
– Discussion of antibiotic choices
• Webcast