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

Preventing ventilator-associated pneumonia: A position paper of the International Society for Infectious Diseases, 2024 update

OBJECTIVES

This review by a panel of experts convened by the International Society for Infectious Diseases aims to consolidate current recommendations for preventing ventilator-associated pneumonia (VAP). It provides insights into VAP rates, the attributable extra length of stay, costs, mortality, and risk factors in high-income and low- and middle-income countries (LMICs).

METHODS

A comprehensive review of existing recommendations and evidence-based strategies for preventing VAP was conducted. The expert panel analyzed data on VAP incidence, associated healthcare burdens, and risk factors across different economic settings to formulate applicable preventive measures.

RESULTS

The review identifies significant differences in VAP rates, healthcare costs, extra length of hospital stay, and mortality between high-income and LMICs. Evidence-based strategies for preventing VAP were highlighted, demonstrating their effectiveness across different healthcare settings.

CONCLUSION

The recommendations and insights provided in this position paper aim to guide healthcare professionals in effectively preventing VAP. The adoption of evidence-based preventive strategies can potentially reduce VAP rates, and associated costs, and improve patient outcomes in both high-income and LMICs.

Multimodal strategies for the implementation of infection prevention and control interventions-update of a systematic review for the WHO guidelines on core components of infection prevention and control programmes at the facility level

BACKGROUND

Health care-associated infections (HAIs) remain a significant challenge worldwide, and the use of multimodal strategies is recommended by the WHO to enhance infection prevention.

OBJECTIVES

To update the systematic review on facility level infection prevention and control interventions on the WHO core component of using multimodal strategies.

METHODS

Data sources: Medline (by PubMed), EMBASE, CINAHL, and the Cochrane library.

STUDY ELIGIBILITY CRITERIA

Randomized controlled studies, interrupted time series, and before-after studies in acute care settings, from November 24, 2015 to June 30, 2023.

PARTICIPANTS

Both paediatric and adult populations.

INTERVENTIONS

Infection prevention and control interventions implemented with at least three WHO multimodality elements. Assessment of risk of bias: Effective practice and organisation of care and integrated quality criteria for review of multiple study designs tools. Methods of data synthesis: Descriptive data synthesis.

RESULTS

Of 5678 identified titles and abstracts, 32 publications were eligible for data extraction and analysis. Five non-controlled before-after studies were excluded due to an insufficient integrated quality criteria for review of multiple study designs score. Of the remaining 27 studies, nine reported on the effect of multimodal strategies to reduce device-associated HAIs, four on surgical site infections, eight on infections due to antimicrobial resistance and six on hand hygiene (HH) compliance. Eleven were controlled studies (randomized controlled studies or controlled before-after studies), nine interrupted time series and seven non-controlled before-after studies. Twenty-two of the studies originated from high-income countries, and the overall quality was medium to low. Twenty studies showed either significant HAI reductions or HH improvement.

CONCLUSION

Most studies demonstrate a significant effect on HAI prevention and HH improvement after applying a multimodal strategy. However, the quality of evidence remains low to moderate, with few studies from low-income or middle-income countries. Future research should focus on higher quality studies in resource limited settings.

Assessing the Impact of Oral Care Micro-courses on ICU Nurses' Compliance Through a Mixed-Effects Model: A Quasi-experimental Study

Background Ventilator-associated pneumonia (VAP) is a common and severe hospital-acquired infection, and oral care is an effective preventive measure. However, the compliance and quality of oral care among intensive care unit (ICU) nurses need improvement. Methods This quasi-experimental study was conducted in two ICUs at the first affiliated hospital of Gannan Medical University, Ganzhou, China, involving 74 ICU nurses. The participants were allocated to either a micro-course education group or a conventional education group. Of these, 32 nurses were from the General ICU, and 42 were from the Cardiac ICU. Both groups received oral care education, with the micro-course group receiving video-based instruction, and the conventional group receiving PowerPoint-based training (Microsoft® Corp., Redmond, WA, USA). Data on oral care compliance and levels of Knowledge, Attitudes, and Practices (KAP) were collected at baseline and during follow-ups over one month. Statistical analysis was conducted using a mixed-effects model to compare outcomes between the groups, highlighting variations in ICU nurses' oral care practices across different ICU settings. Results Both education methods had statistically significant effects. The micro-course education group showed earlier and more pronounced improvements in oral care compliance. Quantitatively, the micro-course group experienced a mean increase in compliance of 0.281 (p = 0.032) at the third follow-up, whereas the conventional group saw a mean increase of 0.261 (p = 0.042) at the fifth follow-up. Additionally, KAP levels in both groups improved significantly (p < 0.001). Conclusion This study demonstrates that micro-course education has a statistically significant impact on ICU nurses' oral care compliance and levels of KAP in the short term. Although there was no significant difference in oral care compliance between the micro-course and conventional education methods, the micro-course showed certain advantages in teaching quality. Long-term studies are needed to evaluate the sustainability of these improvements. Promoting micro-course education in ICU nursing practice may enhance oral care practices and potentially reduce the incidence of VAP.

Implementing strategies to prevent infections in acute-care settings

This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.

Narrative Review of the Epidemiology of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia in Gulf Cooperation Council Countries

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are the most common healthcare-associated infections, with rates varying between countries. Antimicrobial resistance (AMR) among common HAP/VAP pathogens has been reported, and multidrug resistance (MDR) is of further concern across Middle Eastern countries. This narrative review summarizes the incidence and pathogens associated with HAP/VAP in hospitals across Gulf Cooperation Council (GCC) countries. A PubMed literature search was limited to available data on HAP or VAP in patients of any age published within the past 10 years. Reviews, non-English language articles, and studies not reporting HAP/VAP data specific to a GCC country were excluded. Overall, 41 articles, a majority of which focused on VAP, were selected for inclusion after full-text screening. Studies conducted over multiple years showed a general reduction in VAP rates over time, with Gram-negative bacteria the most commonly reported pathogens. Gram-negative isolates reported across GCC countries included Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Rates of AMR varied widely among studies, and MDR among A. baumannii, K. pneumoniae, Escherichia coli, P. aeruginosa, and Staphylococcus aureus isolates was commonly reported. In Saudi Arabia, between 2015 and 2019, rates of carbapenem resistance among Gram-negative bacteria were 19-25%; another study (2004-2009) reported antimicrobial resistance rates in Acinetobacter species (60-89%), P. aeruginosa (13-31%), and Klebsiella species (100% ampicillin, 0-13% other antimicrobials). Although limited genotype data were reported, OXA-48 was found in ≥ 68% of patients in Saudi Arabia with carbapenem-resistant Enterobacteriaceae infections. Ventilator utilization ratios varied across studies, with rates up to 0.9 reported in patients admitted to adult medical/surgical intensive care units in both Kuwait and Saudi Arabia. VAP remains a burden across GCC countries albeit with decreases in rates over time. Evaluation of prevention and treatment measures and implementation of a surveillance program could be useful for the management of HAP and VAP.

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

BACKGROUND AND AIM

Standard airway care can reduce the incidence of ventilator-associated pneumonia (VAP). This study aimed to determine the effect of implementing infection control guidelines on the incidence of VAP in patients admitted to the intensive care unit (ICU).

MATERIALS AND METHODS

In this clinical trial, 121 patients admitted to the intensive care units of Golestan and Imam Khomeini hospitals of Ahvaz, Iran who were under mechanical ventilation were assigned to two groups of control and intervention in non-randomly allocation. The study was conducted in two consecutive periods. In the intervention group, infection control guidelines were performed to prevent VAP and in the control group, routine care was performed. Data collection is done by used a three-part instrument. The first part included questions on the patients' demographics and clinical information. The second part was the modified clinical pulmonary infection scale (MCPIS) for the early detection of VAP. The third part of the data collection instrument was a developed checklist through literature review. The MCPIS was completed for all patients on admission and the 5th day of the study.

RESULTS

The two groups were homogenous respecting their baseline characteristics (P > 0.05) including the mean MCPIS score (P > 0.05). However, the intervention group had lower body temperature (P < 0.001), lower white blood cell counts (P < 0.038), lower MCPIS score (P < 0.001), and higher PaO2/FIO2 (P < 0.013) at the end of the study. The incidence of VAP was significantly lower in the intervention group when compared to the control group (i.e. 30% vs. 65.6%, P < 0.001).

CONCLUSIONS

The implementation of infection control guidelines could significantly reduce the incidence of VAP and its diagnostic indicators in patients admitted to the ICU. Nurses are advised to use these guidelines to prevent VAP in patients admitted to ICU.

Risk factors for mortality in ICU patients in 10 middle eastern countries: The role of healthcare-associated infections

PURPOSE

The International Nosocomial Infection Control Consortium (INICC) found a high mortality rate in ICUs of the Middle East (ME). Our goal was to identify mortality risk factor (RF) in ICUs of the ME.

MATERIALS

From 08/01/2003 to 02/12/2022, we conducted a prospective cohort study in 236 ICUs of 77 hospitals in 44 cities in 10 countries of ME. We analyzed 16 independent variables using multiple logistic regression.

RESULTS

66,440 patients, hospitalized during 652,167 patient-days, and 13,974 died. We identified following mortality RF: Age (adjusted odds ratio (aOR):1.02;p < 0.0001) rising risk 2% yearly; length of stay (LOS) (aOR:1.02;p < 0.0001) rising the risk 2% per day; central line (CL)-days (aOR:1.01;p < 0.0001) rising risk 1% per day; mechanicalventilator (MV) utilization-ratio (aOR:14.51;p < 0.0001); CL-associated bloodstream infection (CLABSI) acquisition (aOR):1.49;p < 0.0001); ventilator-associated pneumonia (VAP) acquisition (aOR:1.50;p < 0.0001); female gender (OR:1.14;p < 0.0001); hospitalization at a public-hospital (OR:1.31;p < 0.0001); and medical-hospitalization (aOR:1.64;p < 0.0001). High-income countries showed lowest risk (aOR:0.59;p < 0.0001).

CONCLUSION

Some identified RF are unlikely to change, such as country income-level, facility ownership, hospitalization type, gender, and age. Some can be modified; LOS, CL-use, MV-use, CLABSI, VAP. So, to lower the mortality risk in ICUs, we recommend focusing on strategies to shorten the LOS, reduce CL and MV-utilization, and use evidence-based recommendations to prevent CLABSI and VAP.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2013-2018, Adult and Pediatric Units, Device-associated Module

BACKGROUND

We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific.

METHODS

Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied.

RESULTS

We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases.

CONCLUSIONS

DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them.

Development of a nursing website for critical care regarding healthcare-associated infections

OBJECTIVE

to describe the development of a website about the main healthcare-associated infections and the respective bundles to prevent these diseases, oriented toward intensive care unit nursing.

METHODS

experience report describing the development of technological innovation by nurses, using computational tools and technological production methodological research and following the product development process.

RESULTS

nurses developed an educational website which can be accessed through computers, tablets, and smartphones at the electronic address irastis.com and focuses on healthcare-associated infections.

FINAL CONSIDERATIONS

digital technologies have contributed to fulfill demands in health care, research, and education. The developed website has the potential to support reduction in healthcare-associated infection rates, since it makes preventive measures for these infections available and refers users to publication environments that systematize the implementation of the bundles.

Critical care nurses' compliance and barriers toward ventilator-associated pneumonia prevention guidelines: cross-sectional survey

OBJECTIVES

This study aims to determine the compliance of critical care nurses with the ventilator-associated pneumonia prevention guidelines and the factors that affect their compliance. We also explored the barriers faced by the nurses in the implementation of these guidelines.

METHODS

A cross-sectional descriptive survey was conducted using a self-administered questionnaire containing 17 recommended strategies to prevent ventilator-associated pneumonia and 15 possible barriers. All critical care nurses of varying qualifications, levels of experience, and nationalities working in adult ICUs were invited. Between January and March 2018, the questionnaire was distributed to 283 nurses at eight ICUs in five public hospitals in Almadinah Almunawwarah, KSA.

RESULTS

A total of 229 invitees responded to the questionnaire. The mean compliance score was 85.9%. More than half (54%) of the sample had a high or acceptable compliance level. The lowest compliance rate was reported for the suctioning of subglottic secretions. The main reported barriers were the shortage of nursing staff, forgetfulness, and hospital cost control policies. Working in general ICUs with the capacity of 10-15 beds or prior education related to ventilator-associated pneumonia prevention influenced the nurses' compliance.

CONCLUSION

In our study, the overall compliance of the critical care nurses with the ventilator-associated pneumonia prevention guidelines is acceptable. Shortage of nursing staff, forgetfulness, and cost control policies were the main reported barriers to compliance.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 204 intensive care units of 57 hospitals in 19 cities of India: International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied in developing countries, and data on their incidence by number of device-days are not available.

METHODS

Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013 to May 31, 2019 in 204 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 57 hospitals in 19 cities of India. We applied US INICC definition criteria and reported methods using the INICC Surveillance Online System.

RESULTS

We followed 7,513 ICU patients for 296,893 bed-days and 295,795 short term peripheral venous catheter (PVC)-days. We identified 863 PVCR-BSIs, amounting to a rate of 2.91/1,000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 4.14%, and 11.59% in patients with PVCR-BSI. The length of stay in patients with PVC but without PVCR-BSI was 4.13 days, and 5.9 days in patients with PVCR-BSI. The micro-organism profile showed 68% of gram negative bacteria: Escherichia coli (23%), Klebsiella spp (15%), Pseudomonas aeruginosa (5%), and others. The predominant gram-positive bacteria were Staphylococcus aureus (10%).

CONCLUSIONS

PVCR-BSI rates found in our ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 246 intensive units of 83 hospitals in 52 cities of 14 countries of Middle East: Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates-International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied, and data on their incidence by number of device-days is not available.

METHODS

Prospective, surveillance study on PVCR-BSI conducted from September 1st, 2013 to 31st Mays, 2019 in 246 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 83 hospitals in 52 cities of 14 countries in the Middle East (Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates). We applied U.S.

RESULTS

We followed 31,083 ICU patients for 189,834 bed-days and 202,375 short term peripheral venous catheter (PVC)-days. We identified 470 PVCR-BSIs, amounting to a rate of 2.32/1000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 10.38%, and 29.36% in patients with PVC and PVCR-BSI. The mean length of stay in patients with PVC but without PVCR-BSI was 5.94 days, and 16.84 days in patients with PVC and PVCR-BSI. The microorganism profile showed 55.2 % of gram-positive bacteria, with Coagulase-negative Staphylococci (31%) and Staphylococcus aureus (14%) being the predominant ones. Gram-negative bacteria accounted for 39% of cases, and included: Escherichia coli (7%), Klebsiella pneumoniae (8%), Pseudomonas aeruginosa (5%), Enterobacter spp. (3%), and others (29.9%), such as Serratia marcescens.

CONCLUSIONS

PVCR-BSI rates found in our ICUs were much higher than rates published from USA, Australia, and Italy. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 727 intensive care units of 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific Regions: International Nosocomial Infection Control Consortium (INICC) findings

BACKGROUND

Short-term peripheral venous catheter-related bloodstream infection (PVCR-BSI) rates have not been systematically studied in resource-limited countries, and data on their incidence by number of device days are not available.

METHODS

Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013, to May 31, 2019, in 727 intensive care units (ICUs), by members of the International Nosocomial Infection Control Consortium (INICC), from 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific regions. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System.

RESULTS

We followed 149,609 ICU patients for 731,135 bed days and 743,508 short-term peripheral venous catheter (PVC) days. We identified 1,789 PVCR-BSIs for an overall rate of 2.41 per 1,000 PVC days. Mortality in patients with PVC but without PVCR-BSI was 6.67%, and mortality was 18% in patients with PVC and PVCR-BSI. The length of stay of patients with PVC but without PVCR-BSI was 4.83 days, and the length of stay was 9.85 days in patients with PVC and PVCR-BSI. Among these infections, the microorganism profile showed 58% gram-negative bacteria: Escherichia coli (16%), Klebsiella spp (11%), Pseudomonas aeruginosa (6%), Enterobacter spp (4%), and others (20%) including Serratia marcescens. Staphylococcus aureus were the predominant gram-positive bacteria (12%).

CONCLUSIONS

PVCR-BSI rates in INICC ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs in resource-limited countries.

Nosocomial Infections and Ventilator-Associated Pneumonia in Cancer Patients

Nosocomial infections or healthcare-acquired infections are a common cause of increased morbidity and mortality among hospitalized patients. Cancer patients are at an increased risk for these infections due to their immunosuppressed states. Considering these adverse effects on and the socioeconomic burden, efforts should be made to minimize the transmission of these infections and make the hospitals a safer environment. These infection rates can be significantly reduced by the implementing and improving compliance with the “care bundles.”

This chapter will address the common nosocomial infections such as ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSI), including preventive strategies and care bundles for the same.

"The multimodal approach for ventilator-associated pneumonia prevention"-requirements for nationwide implementation

The multimodal approach for ventilator-associated pneumonia (VAP) prevention has been shown to be a successful strategy in reducing VAP rates in many intensive care units (ICU) in some countries. The simultaneous application of several measures or "bundles" to reduce VAP rates has achieved a higher impact than the progressive implementation of the individual interventions. The ultimate objective of recommendation bundles is their integration in the culture of routine healthcare of the staff in charge of ventilated patients for accomplished rates to persist over time. The noteworthy elements of this new strategy include the selection of the individual recommendations of the bundle, education of care workers (HCW) in the culture of patient safety, audit of compliance with the recommendations, commitment of the hospital management to support implementation, nomination and empowerment of local leaders of the projects in ICUs, both physicians and nurses, and the continuous collection of VAP episodes. The implementation of this new strategy is not an easy task, as both its inherent strength and important barriers to its application have become evident, which need to be overcome for maximal reduction of VAP rates.