Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish "Zero-VAP" bundle

Selective decontamination of the digestive tract in a burns unit reduces the incidence of hospital-acquired infections: A retrospective before-and-after cohort study

OBJECTIVE

To evaluate the effect of selective decontamination of the digestive tract (SDD) on hospital-acquired infections (HAIs) in patients with acute burn injury requiring admission to a Burns Unit (BU).

DESIGN

Retrospective before-and-after cohort study, between January 2017 and June 2023. SDD was implemented in March 2019, dividing patients into two groups.

SETTING

Four-bed BU, in a referral University Hospital in Spain.

PATIENTS

All the patients admitted during the study period were eligible for analysis. Patients who died or were discharged within 48hours of admission, and patients with an estimated survival less than 10% not considered for full escalation of therapy were excluded.

INTERVENTION

SDD comprised the administration of a 4-day course of an intravenous antibiotic, and an oral suspension and oral topical paste of non-absorbable antibiotics during the stay in the BU.

MAIN VARIABLE OF INTEREST

Incidence of HAIs during the stay in the BU.

SECONDARY OUTCOMES

incidence of specific types of infections by site (bacteremia, pneumonia, skin and soft tissue infection) and microorganism (Gram-positive, Gram-negative, fungi), and safety endpoints.

RESULTS

We analyzed 72 patients: 27 did not receive SDD, and 45 received SDD. The number of patients who developed HAIs were 21 (77.8%) and 21 (46.7%) in the non-SDD and the SDD groups, respectively (p=0.009). The number of hospital-acquired infectious episodes were 2.52 (1.21-3.82) and 1.13 (0.54-1.73), respectively (p=0.029).

CONCLUSIONS

SDD was associated with a reduced incidence of bacterial HAIs and a decrease in the number of infectious episodes per patient.

Chlorhexidine is not effective at any concentration in preventing ventilator-associated pneumonia: a systematic review and network meta-analysis

INTRODUCTION

Oral chlorhexidine has been widely used for ventilator-associated pneumonia prevention in the critical care setting; however, previous studies and evidence synthesis have generated inconsistent findings. Our study aims to investigate if different concentrations of oral chlorhexidine may be effective in preventing such complication in intensive care unit patients.

METHODS

After pre-registration (Open Science Framework: 8CUKF), we conducted a network meta-analysis with the following PICOS: adult patients (age > 18 years old) undergoing invasive mechanical ventilation admitted in ICU (P); any concentration of chlorhexidine used for oral hygiene (I); placebo, sham intervention, usual care, or no intervention (C); rate of VAP (primary outcome), mechanical ventilation length, ICU length of stay (LOS), hospital LOS, mortality (secondary outcomes) (O); randomized controlled trials (S). We used the following database: PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and EMBASE without any limitation in publication date or language.

RESULTS

Chlorhexidine did not demonstrate any significant advantage over the control group in preventing ventilator-associated pneumonia or reducing mortality, duration of mechanical ventilation, length of stay in the intensive care unit, or overall mortality.

CONCLUSIONS

Chlorhexidine oral decontamination does not reduce the rate of ventilator-associated pneumonia in critically ill adult patients and its routine use could not be recommended.

TRIAL REGISTRATION

Registration number: Open Science Framework: 8CUKF.

Prevention of ventilator-associated pneumonia through care bundles: A systematic review and meta-analysis

Background

Ventilator-associated pneumonia (VAP) represents a common hospital-acquired infection among mechanically ventilated patients. We summarized evidence concerning ventilator care bundles to prevent VAP.

Methods

A systematic review and meta-analysis were performed. Randomized controlled trials and controlled observational studies of adults undergoing mechanical ventilation (MV) for at least 48 h were considered for inclusion. Outcomes of interest were the number of VAP episodes, duration of MV, hospital and intensive care unit (ICU) length of stay, and mortality. A systematic search was conducted in the MEDLINE, the Cochrane Library, and the Web of Science between 1985 and 2022. Results are reported as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI). The PROSPERO registration number is CRD42022341780.

Results

Thirty-six studies including 116,873 MV participants met the inclusion criteria. A total of 84,031 participants underwent care bundles for VAP prevention. The most reported component of the ventilator bundle was head-of-bed elevation (n=83,146), followed by oral care (n=80,787). A reduction in the number of VAP episodes was observed among those receiving ventilator care bundles, compared with the non-care bundle group (OR=0.42, 95% CI: 0.33, 0.54). Additionally, the implementation of care bundles decreased the duration of MV (MD=-0.59, 95% CI: -1.03, -0.15) and hospital length of stay (MD=-1.24, 95% CI: -2.30, -0.18) in studies where educational activities were part of the bundle. Data regarding mortality were inconclusive.

Conclusions

The implementation of ventilator care bundles reduced the number of VAP episodes and the duration of MV in adult ICUs. Their application in combination with educational activities seemed to improve clinical outcomes.

Selective decontamination of the digestive tract: concept and application

Selective digestive decontamination (SDD) is a prophylactic strategy aimed at preventing or eradicating bacterial overgrowth in the intestinal flora that precedes the development of most infections in the Intensive Care Unit. SDD prevents serious infections, reduces mortality, is cost-effective, has no adverse effects, and its short- or long-term use is not associated with any significant increase in antimicrobial resistance. SDD is one of the most widely evaluated interventions in critically ill patients, yet its use is not widespread. The present article offers a narrative review of the most relevant evidence and an update of the pathophysiological concepts of infection control supporting the use of SDD.

Nursing Care of Patient With Tracheostomy Tube Cuff Rupture Caused by Tracheal Polyp: A Case Report

INTRODUCTION

Tracheostomy is common in patients with critical illness. Mechanical ventilation requires the airway to be closed by an inflated tracheostomy tube cuff. Tracheostomy tube cuff rupture is a serious complication of airway management. This case study summarizes the nursing care of a patient who received prolonged mechanical ventilation and had recurrent tracheostomy tube cuff ruptures caused by a tracheal polyp.

CLINICAL FINDINGS AND DIAGNOSIS

An 81-year-old woman was admitted because of acute exacerbation of chronic obstructive pulmonary disease. The patient had undergone percutaneous tracheostomy 3 years earlier because of difficulty in weaning from the ventilator and had recurrent lung infections that led to respiratory failure. A tracheal polyp was identified as the cause of multiple tracheostomy tube cuff ruptures.

OUTCOMES

After the tracheal polyp was removed with bronchofiberscope guidance, the patient remained hospitalized because of difficulty in ventilator weaning but had no further tracheostomy tube cuff ruptures.

CONCLUSION

Tracheal polyps that cause tracheostomy tube cuff ruptures are rare, but nurses should be alert to their occurrence. If a tube cuff ruptures in a patient receiving long-term mechanical ventilation, bronchoscopy should be performed as soon as possible to allow for early identification of the cause and ensure patient safety.

Impact of the "Zero Resistance" program on acquisition of multidrug-resistant bacteria in patients admitted to Intensive Care Units in Spain. A prospective, intervention, multimodal, multicenter study

OBJECTIVE

To assess the impact of a multimodal interventional project ("Zero Resistance") on the acquisition of multidrug-resistant bacteria (MDR-B) during the patient's ICU stay.

DESIGN

Prospective, open-label, interventional, multicenter study.

SETTING

103 ICUs.

PATIENTS

Critically ill patients admitted to the ICUs over a 27-month period.

INTERVENTIONS

Implementation of a bundle of 10 recommendations to prevent emergence and spread of MDR-B in the ICU.

MAIN VARIABLE OF INTEREST

Rate of patients acquiring MDR-B during their ICU stay, with differentiation between colonization and infection.

RESULTS

A total of 139,505 patients were included. In 5409 (3.9%) patients, 6020 MDR-B on ICU admission were identified, and in 3648 (2.6%) patients, 4269 new MDR-B during ICU stay were isolated. The rate of patients with MDR-B detected on admission increased significantly (IRR 1.43, 95% CI 1.31-1.56) (p<0.001) during the study period, with an increase of 32.2% between the initial and final monthly rates. On the contrary, the rate of patients with MDR-B during ICU stay decreased non-significantly (IRR 0.93, 95% CI 0.83-1.03) (p=0.174), with a 24.9% decrease between initial and final monthly rates. According to the classification into colonization or infection, there was a highly significant increase of MDR-B colonizations detected on admission (IRR 1.69, 95% CI 1.52-1.83; p<0.0001) and a very significant decrease of MDR-B-infections during ICU stay (IRR 0.67, 95% CI 0.57-0.80, p<0.0001).

CONCLUSIONS

The implementation of ZR project-recommendations was associated with a significantly reduction an infection produced by MDR-B acquired during the patient's ICU stay.

[Update of the recommendations of the Pneumonia Zero project]

La pandemia por el SARS-Cov-2 ha impactado negativamente en la aplicación de las recomendaciones de Neumonía Zero y se ha acompañado de un incremento de las tasas de Neumonía asociada a ventilación mecánica (NAVM) en las unidades de cuidados intensivos de España. Con el objetivo de disminuir las tasas actuales a 7 episodios por 1000 días de VM, se han actualizado las recomendaciones del proyecto inicial.

Se identificaron, 27 medidas que se clasificaron en 12 medidas funcionales (posición semisentada, higiene estricta de manos, entrenamiento para manipular la vía aérea, valoración diaria de posible extubación, protocolización del destete, traqueostomía precoz, ventilación no invasiva, vigilancia microbiológica, cambio de tubuladuras, humidificación, fisioterapia respiratoria, nutrición enteral postpilórica), 7 mecánicas (control de la presión del neumotaponamiento, tubos con aspiración subglótica, nutrición con sondas de bajo calibre/en intestino delgado, aspiración de secreciones con circuitos cerrados/abiertos, filtros respiratorios, cepillado de dientes, técnicas de presión negativa en la aspiración de secreciones) y 8 farmacológicas (descontaminación selectiva digestiva, descontaminación orofaríngea, ciclo corto de antibióticos, higiene de boca con clorhexidina, antibióticos inhalados, rotación de antibióticos, probióticos, anticuerpos monoclonales).

Cada medida se analizó de forma independiente, por al menos dos miembros del grupo de trabajo, mediante una revisión sistemática de la literatura y una revisión iterativa de las recomendaciones de las sociedades científicas y/o grupos de expertos.

Para la clasificación de la calidad de la evidencia y fuerza de las recomendaciones se siguió la propuesta del grupo GRADE. Para determinar el grado de recomendación, cada medida fue puntuada por todos los miembros del grupo de trabajo en relación con su efectividad, tolerabilidad y aplicabilidad en las UCI españolas a corto plazo de tiempo. Se solicitó el apoyo de expertos externos en alguna de las medidas que se revisaron. Se seleccionaron aquellas medidas que alcanzaron la máxima puntuación.

Management of Ventilator-Associated Pneumonia: Quality Assessment of Clinical Practice Guidelines and Variations in Recommendations on Drug Therapy for Prevention and Treatment

Purpose: To assess the quality of clinical practice guidelines (CPGs) related to drug therapy for prevention and control of ventilator-associated pneumonia (VAP) and compare the differences and similarities between recommendations.

Methods: Electronic databases (including PubMed, Cochrane library, Embase, Web of Science), guideline development organizations, and professional societies were searched to identify CPGs for VAP from 20 January 2012 to 20 January 2022. The Appraisal of Guidelines Research & Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. The recommendations on drug therapy for prevention and treatment for each guideline were extracted, and then a descriptive synthesis was performed to analyze the scope/topic, and consistency of the recommendations.

Results: Thirteen CPGs were included. The median score and interquartile range (IQR) in each domain are shown below: scope and purpose 72.22% (63.89%,83.33%); stakeholder involvement 44.44% (38.89%,52.78%); rigor of development 43.75% (31.25%,57.29%); clarity and presentation 94.44% (77.78%,94.44%); applicability 20.83 (8.34%,33.34%) and editorial independence 50% (33.33%,66.67%). We extracted 21 recommendations on drug therapy for prevention of VAP and 51 recommendations on drugs used for treatment. Some controversies remained among the included guidelines.

Conclusion: There is considerable variability in the development processes and reporting of VAP guidelines. Despite many similarities, the recommendations still had some inconsistencies in the details. For the prevention and treatment of VAP, local microbial epidemiology and antibiotic sensitivity must be considered, and recommendations should be regularly revised as new evidence emerges.

Should oral chlorhexidine remain in ventilator-associated pneumonia prevention bundles?

Ventilator-associated pneumonia (VAP) is related with high mortality, duration of mechanical ventilation and costs. Recent studies have questioned the safety and effectiveness of oral chlorhexidine to prevent VAP. We sought to verify whether the adverse effects of this substance outweigh its benefits. We searched several databases and selected studies that investigated the use of oral chlorhexidine and its impact on mortality. No association between oral chlorhexidine and lower VAP rates was found on meta-analyses of double-blind randomized trials, however significant increase in mortality was reported. It is speculated that chlorhexidine can cause damage to several organic sectors and cytotoxicity. Although it still can be beneficial in specific settings, robust evidence to recommend its routine application for all mechanically ventilated patients is lacking; therefore, given the possibility of harm, it would be better to follow the principle of non-maleficence until more studies becomes available.

Risk Factors and Protective Factors against Ventilator-Associated Pneumonia-A Single-Center Mixed Prospective and Retrospective Cohort Study

Introduction: Understanding the factors associated with the development of ventilator-associated pneumonia (VAP) in critically ill patients in the intensive care unit (ICU) will allow for better prevention and control of VAP. The aim of the study was to evaluate the incidence of VAP, as well as to determine risk factors and protective factors against VAP. Design: Mixed prospective and retrospective cohort study. Methods: The cohort involved 371 critically ill patients who received standard interventions to prevent VAP. Additionally, patients in the prospective cohort were provided with continuous automatic pressure control in tapered cuffs of endotracheal or tracheostomy tubes and continuous automatic subglottic secretion suction. Logistic regression was used to assess factors affecting VAP. Results: 52 (14%) patients developed VAP, and the incidence density of VAP per 1000 ventilator days was 9.7. The median days to onset of VAP was 7 [4; 13]. Early and late onset VAP was 6.2% and 7.8%, respectively. According to multivariable logistic regression analysis, tracheotomy (OR = 1.6; CI 95%: 1.1 to 2.31), multidrug-resistant bacteria isolated in the culture of lower respiratory secretions (OR = 2.73; Cl 95%: 1.83 to 4.07) and ICU length of stay >5 days (OR = 3.32; Cl 95%: 1.53 to 7.19) were positively correlated with VAP, while continuous control of cuff pressure and subglottic secretion suction used together were negatively correlated with VAP (OR = 0.61; Cl 95%: 0.43 to 0.87). Conclusions: Tracheotomy, multidrug-resistant bacteria, and ICU length of stay >5 days were independent risk factors of VAP, whereas continuous control of cuff pressure and subglottic secretion suction used together were protective factors against VAP.

Endotracheal Tube Cuff Pressure Management: An Observational Study Guided by the SEIPS Model

INTRODUCTION

The aim of the rigorous endotracheal tube cuff pressure (ETTCP) management is to maintain cuff pressures within the recommended values during the mechanical ventilation period. However, hyperinflation or hypoinflation of cuff has been reported because of inconsistent clinical practices in intensive care unit (ICU) settings. Furthermore, there is no available best evidence for clinical decision-making regarding the ETTCP management provided by international institutes.

PURPOSE

The aim of this study was to examine the ETTCP management work system in ICU settings in urban hospitals of Turkey and the United States using the Systems Engineering Initiative for Patient Safety model.

METHODS

This was a direct observational, prospective field study, in which the COREQ (Consolidated Criteria for Reporting Qualitative Research) tool was used. The direct observations and follow-up interviews were conducted, and the results were reported using the Systems Engineering Initiative for Patient Safety model.

RESULTS

We identified important characteristics of the ETTCP management work system in each of the 4 ICU and differences across the settings.

CONCLUSION

Common use of the evidence-based and internationally used protocols may standardize the management of ETTCP, improve communication among ICU staff, and promote desired patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

There is a need for developing strategies to provide standardized ETTCP management and to improve patient's quality of care. To improve the patient outcomes and quality of care, ICU managers should consider clear expectations for ETTCP management in each job description, structured and evidence-based protocols, and effective communication among disciplines and provide teaching opportunities to encourage physicians, nurses, and respiratory therapists to meet their educational needs.

Investigation of the airway management practice of emergency department ward nurses: a nationwide survey in China

OBJECTIVES

To investigate the airway management equipment and clinical practice in emergency department wards in China, and to explore the factors that influenced the nurses' airway management practice.

DESIGN

Cross-sectional study.

SETTING

A nationwide survey covering the seven administrative regions of China (North China, Northeast China, East China, Central China, South China, Southwest China and Northwest China).

PARTICIPANTS

The nurses had to be registered nurses who worked in adult emergency department wards of the selected hospitals.

MEASURES

An online survey was designed, piloted and distributed to the members of the Emergency Medicine Committee of the Chinese Nursing Association, and the nurses from the members' hospitals were invited to participate. The questionnaire was used to determine nurses' clinical practice scores of airway management in emergency wards.

RESULTS

Finally, we collected 995 valid questionnaires from 31 provinces and 143 districts in China. Among them, 361 (36.28%) nurses responded that their departments used open suction system (OSS) in clinical work, the major barrier for closed suction system (CSS) reported by 630 respondents (63.32%) was cost. Significant differences in all three scores were found in age, nursing experience years, technical title, airway management training experience and nursing specialist (all p<0.05). Correlations were found among airway management attitude, practice of sputum aspiration and practice of ventilator care bundles (r=0.655, r=0.543 and r=0.763, all p<0.001).

CONCLUSIONS

Chinese emergency department managers need to identify better methods for assessing equipment availability in OSS. CSS can be a choice when costs, status of the individual patient and severity of disease are comprehensively considered. Emergency department nurses' scores of airway management practice were affected by demographic and job-related characteristics; regular training should be encouraged, and equipment and resources should be guaranteed to improve airway management quality and optimise patient outcomes.

Management of pneumonia in critically ill patients

Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.

A comparison of diagnostic algorithms and clinical parameters to diagnose ventilator-associated pneumonia: a prospective observational study

Background

Suspicion and clinical criteria continue to serve as the foundation for ventilator-associated pneumonia (VAP) diagnosis, however the criteria used to diagnose VAP vary widely. Data from head-to-head comparisons of clinical diagnostic algorithms is lacking, thus a prospective observational study was performed to determine the performance characteristics of the Johanson criteria, Clinical Pulmonary Infection Score (CPIS), and Centers for Disease Control and Prevention’s National Healthcare Safety Network (CDC/NHSN) criteria as compared to Hospital in Europe Link for Infection Control through Surveillance (HELICS) reference standard.

Methods

A prospective observational cohort study was performed in three mixed medical-surgical ICUs from one academic medical center from 1 October 2016 to 30 April 2018. VAP diagnostic criteria were applied to each patient including CDC/NHSN, CPIS, HELICS and Johanson criteria. Tracheal aspirate cultures (TAC) and serum procalcitonin values were obtained for each patient.

Results

Eighty-five patients were enrolled (VAP 45, controls 40). Using HELICS as the reference standard, the sensitivity and specificity for each of the assessed diagnostic algorithms were: CDC/NHSN (Sensitivity 54.2%; Specificity 100%), CPIS (Sensitivity 68.75%; Specificity 95.23%), Johanson (Sensitivity 67.69%; Specificity 95%). The positive TAC rate was 81.2%. The sensitivity for positive TAC with the serum procalcitonin level > 0.5 ng/ml was 51.8%.

Conclusion

VAP remains a considerable source of morbidity and mortality in modern intensive care units. The optimal diagnostic method remains unclear. Using HELICS criteria as the reference standard, CPIS had the greatest comparative diagnostic accuracy, whereas the sensitivity of the CDC/NHSN was only marginally better than a positive TAC plus serum procalcitonin > 0.5 ng/ml. Algorithm accuracy was improved by adding serum procalcitonin > 0.5 ng/ml, but not positive quantitative TAC.

Trial Registration: Not indicated for this study type.

Role of head-of-bed elevation in preventing ventilator-associated pneumonia bed elevation and pneumonia

BACKGROUND

Elevating the head of bed (HOB) to 30° to 45° is an evidence-based recommendation to prevent ventilator-associated pneumonia (VAP). However, the available scientific data are inconclusive regarding the optimal degree of HOB elevation which is safe and effective for mechanically ventilated patients.

AIMS AND OBJECTIVES

To investigate the impact a of semirecumbent position at 30° and 45°on the development of VAP as compared with aHOB elevation to <30°.

METHODS

A 5-day, single centre, prospective, randomized, controlled, parallel group, three-arm study was conducted in adult patients on mechanical ventilation staying in the intensive care unit. Patients were randomly placed in <30°, 30°, or 45° HOB elevation position on the day of intubation and followed up for 5 days. They were assessed in terms of the development of microbiologically confirmed VAP (by the culture of endotracheal aspirate) over the study period.

RESULTS

Sixty patients (20 in each arm) completed the study. VAP occurred in 55%, 25%, and 20% of patients in the HOB elevation to <30°, 30°, and 45°study arms, respectively. The frequency of VAP was significantly lower in the 45° compared with the <30° study arm (P = .022); there were no significant differences between the <30° and 30° as well as the 45° and 30° study groups. Unlike the frequency of VAP, the timing of the VAP (early or late) was not dependent on the degree of HOB elevation (P = .703).

CONCLUSIONS

Keeping the mechanically ventilated patients in a semirecumbent position as close to 45°as possible should be the goal to prevent the development of VAP. The backrest elevation <30° should be avoided unless medically indicated.

RELEVANCE TO CLINICAL PRACTICE

The study results reaffirm the crucial role of patient positioning, an essential nursing care intervention, in preventing VAP. Intensive care nurses can contribute to improving the VAP rates and outcomes by placing and keeping the patients in the correct position.

Multi-criteria risk evaluation model for developing ventilator-associated pneumonia

Ventilator-associated pneumonia is a hospital-acquired infection of the lungs occurring in mechanically ventilated patients. An active risk management approach can prevent the occurrence of the disease and promote positive organizational changes, subsequently decreasing mortality and hospitalization costs. Using scientific and clinical practice knowledge, a risk evaluation model was developed to identify patients more at risk of developing the disease. For this purpose, a Decision Expert qualitative multi-criteria decision method was used, in which alternatives are evaluated according to predetermined hierarchically arranged criteria. Characteristics of each evaluated alternative are described by the members of an interdisciplinary expert team and are represented by the values of the basic criteria. Values of hierarchically higher aggregated criteria are computed in an upwards fashion according to utility functions, which are defined as simple logical rules. This method is integrated into a software solution, DEXi. The approach is applicable to vastly diverse decision problems and has been successfully used before for health-related decision support. The designed model was tested using actual clinical data. Evaluations of alternatives that most distinctly demonstrated the functionality of the evaluation model were selected and are presented in the results. The evaluation model is intended to assist a holistic evaluation of the risk of developing ventilator-associated pneumonia, by considering patient-related risk factors and the use of preventive measures. The model incorporates nursing-specific data that have hitherto been poorly utilized in preventing ventilator-associated pneumonia and promotes the active engagement of nurses in confronting this interdisciplinary healthcare problem, which has gained more prominence with the onset of COVID-19 disease.

Should oral chlorhexidine remain in ventilator-associated pneumonia prevention bundles?

Ventilator-associated pneumonia (VAP) is related with high mortality, duration of mechanical ventilation and costs. Recent studies have questioned the safety and effectiveness of oral chlorhexidine to prevent VAP. We sought to verify whether the adverse effects of this substance outweigh its benefits. We searched several databases and selected studies that investigated the use of oral chlorhexidine and its impact on mortality. No association between oral chlorhexidine and lower VAP rates was found on meta-analyses of double-blind randomized trials, however significant increase in mortality was reported. It is speculated that chlorhexidine can cause damage to several organic sectors and cytotoxicity. Although it still can be beneficial in specific settings, robust evidence to recommend its routine application for all mechanically ventilated patients is lacking; therefore, given the possibility of harm, it would be better to follow the principle of non-maleficence until more studies becomes available.

Active humidification in mechanical ventilation is not associated to an increase in respiratory infectious complications in a quasi-experimental pre-post intervention study

OBJECTIVE

There is controversy regarding the influence of humidification systems upon the incidence of respiratory infections associated to invasive mechanical ventilation (IMV). An evaluation was made of the differences in the incidence of pneumonia and tracheobronchitis associated to mechanical ventilation (VAP and VAT, respectively) with passive and active humidification.

DESIGN

A retrospective pre-post quasi-experimental study was carried out.

SETTING

A polyvalent ICU with 14 beds.

PATIENTS

All patients connected to IMV for >48h during 2014 and 2016 were included.

INTERVENTIONS

During 2014, passive humidification with an hygroscopic heat and moisture exchanger (HME) was used, while during 2016 active humidification with a heated humidifier (HH) and an inspiratory heated wire was used. Identical measures for the prevention of VAP were established (Zero Pneumonia Project).

MAIN OUTCOME MEASURES

The incidence of VAP and VAT was estimated for 1000 days of IMV in both groups, and statistically significant differences were assessed using Poisson regression analysis.

RESULTS

A total of 287 patients were included (116 with HME and 171 with HH). The incidence density of VAP per 1000 days of IMV was 5.68 in the HME group and 5.80 in the HH group (p=ns). The incidence density of VAT was 3.41 and 3.26 cases per 1000 days of VMI with HME and HH respectively (p=ns). The duration of IMV was identified as a risk factor for VAP.

CONCLUSIONS

In our population, active humidification in patients ventilated for >48h was not associated to an increase in respiratory infectious complications.

Pathogenesis-Targeted Preventive Strategies for Multidrug Resistant Ventilator-Associated Pneumonia: A Narrative Review

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU), accounting for relevant morbidity and mortality among critically ill patients, especially when caused by multidrug resistant (MDR) organisms. The rising problem of MDR etiologies, which has led to a reduction in treatment options, have increased clinician’s attention to the employment of effective prevention strategies. In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing MDR-VAP. Oral hygiene with Chlorhexidine (CHX), CHX body washing, selective oral decontamination (SOD) and/or digestive decontamination (SDD), multiple decontamination regimens, probiotics, subglottic secretions drainage (SSD), special cuff material and shape, silver-coated endotracheal tubes (ETTs), universal use of gloves and contact isolation, alcohol-based hand gel, vaporized hydrogen peroxide, and bundles of care have been addressed. The most convincing evidence came from interventions directly addressed against the key factors of MDR-VAP pathogenesis, especially when they are jointly implemented into bundles. Further research, however, is warranted to identify the most effective combination.

Severe trauma patients and nursing practice-associated infections

AIMS

Our study examined factors influencing the development of healthcare-associated infections in the intensive care unit (ICU) of a tertiary hospital in southern Spain.

BACKGROUND

Healthcare-associated infections are a frequent adverse event, significantly lengthening patient stays in the ICU. Nursing practice is a key factor in the infection control process.

DESIGN

A retrospective longitudinal study with two observation periods (admission and discharge) was performed in an ICU of a tertiary hospital.

METHODS

We analysed patient records for those admitted to this unit coded as CIE 800-959.9 from 2012 to 2016. Using binomial logistic regression analysis, we analysed factors associated with healthcare-associated infections.

RESULTS

We analysed 375 records (men: 78.1%; average age: 46.63 years). Of these, 9.2% patients acquired a healthcare-associated infection during their stay. Nursing practice-related factors significantly associated with the development of infection were the number of days connected to mechanical ventilation and the number of days in the ICU.

CONCLUSION

Healthcare-associated infections in patients with severe trauma admitted to the ICU are mainly associated with the management of invasive techniques. A multidisciplinary approach should focus on the review of action and care plans.

Active humidification in mechanical ventilation is not associated to an increase in respiratory infectious complications in a quasi-experimental pre-post intervention study

OBJECTIVE

There is controversy regarding the influence of humidification systems upon the incidence of respiratory infections associated to invasive mechanical ventilation (IMV). An evaluation was made of the differences in the incidence of pneumonia and tracheobronchitis associated to mechanical ventilation (VAP and VAT, respectively) with passive and active humidification.

DESIGN

A retrospective pre-post quasi-experimental study was carried out.

SETTING

A polyvalent ICU with 14 beds.

PATIENTS

All patients connected to IMV for>48hours during 2014 and 2016 were included.

INTERVENTIONS

During 2014, passive humidification with an hygroscopic heat and moisture exchanger (HME) was used, while during 2016 active humidification with a heated humidifier (HH) and an inspiratory heated wire was used. Identical measures for the prevention of VAP were established (Zero Pneumonia Project).

MAIN OUTCOME MEASURES

The incidence of VAP and VAT was estimated for 1000 days of IMV in both groups, and statistically significant differences were assessed using Poisson regression analysis.

RESULTS

A total of 287 patients were included (116 with HME and 171 with HH). The incidence density of VAP per 1000 days of IMV was 5.68 in the HME group and 5.80 in the HH group (p=ns). The incidence density of VAT was 3.41 and 3.26 cases per 1000 days of VMI with HME and HH respectively (p=ns). The duration of IMV was identified as a risk factor for VAP.

CONCLUSIONS

In our population, active humidification in patients ventilated for>48hours was not associated to an increase in respiratory infectious complications.

Predictors and microbiology of ventilator-associated pneumonia among patients with exacerbation of chronic obstructive pulmonary disease

BACKGROUND

Understanding the risk factors and microbiology of ventilator-associated pneumonia (VAP) among patients with chronic obstructive pulmonary disease (COPD) is important for the application of preventive and therapeutic interventions. Therefore, this study was planned to assess the clinical predictors and microbiological features of VAP among COPD patients.

MATERIALS AND METHODS

This prospective study involved patients with exacerbation of COPD who required mechanical ventilation and admitted in respiratory intensive care unit at a tertiary care teaching hospital. Various baseline demographic and clinical features were compared between patients with VAP and without VAP. Univariate and multivariable analyses were done to assess the impact of demographic and clinical features on the development of VAP.

RESULTS

The study included 100 intubated patients with age (mean ± standard deviation [SD]) of 62.45 ± 8.32 years, duration (median) of COPD of 6 years, and Acute Physiology, Age, and Chronic Health Evaluation score (mean ± SD) of 18.60 ± 4.30. In this cohort, 17 patients developed VAP. Multivariable analysis showed that Sequential Organ Failure Assessment (SOFA) score at admission, re-intubation, and history of previous hospitalization were independent predictors of VAP with odds ratio (95% confidence interval) of 2.70 (1.24, 5.63; P = 0.012), 66.96 (4.86, 922.72; P = 0.002), and 35.92 (2.84, 454.63; P = 0.006), respectively. Acinetobacter baumannii was the most frequent organism (n = 8; 47%), followed by Klebsiella pneumoniae (n = 5; 29%), Pseudomonas aeruginosa (n = 1; 6%), and Enterobacter spp. (n = 1; 6%). All organisms were multidrug resistant (MDR).

CONCLUSIONS

SOFA score at admission, re-intubation, and history of previous hospitalization were independent predictors of VAP. Antimicrobial therapy for VAP should cover MDR Gram-negative organisms.

The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle

INTRODUCTION

Ventilator-associated pneumonia (VAP) is a nosocomial infection that develops 48h after the initiation of mechanical ventilatory support. Current evidence-based guidelines demonstrate that VAP prevention is feasible through the implementation of certain VAP prevention bundle of interventions simultaneously. We aimed in this study to investigate the effect of VAP prevention pre- and post- implementation.

METHODS

This is a single-center, cohort study that took place at the Pediatric Intensive Care Unit (PICU) of King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia from January 2015 to March 2018 and assessed the rate of VAP before and after implementation of the bundle.

RESULTS

The study included 141 children, 95 were included from the pre-bundle group and 36 from the bundle group. VAP developed in 35% of the pre-bundle group compared to 31% of the bundle group (p=0.651) with incidence rates equaled to 18 and 12 per 1000 ventilator days, respectively.

CONCLUSION

This study found that VAP bundle did not significantly reduce VAP rate in the PICU. Further large prospective multi-center studies with longer intervention duration are indicated to investigate the benefits of using VAP prevention bundle.

Hand Hygiene Teaching Strategies among Nursing Staff: A Systematic Review

Background: Patient safety is a priority of any healthcare system, and one of the most effective measures is hand hygiene. For this, it is important that health staff have correct adherence and perform the technique properly. Otherwise, the incidence of nosocomial infections can increase, with consequent complications. The aim here was to analyze hand hygiene training and the effectiveness of different methods and educational strategies among nurses and whether they maintained correct adherence over time. Methods: A systematic review was conducted in the sources CINAHL (Cumulative Index to Nursing and Allied Health Literature), Dialnet, Lilacs (Latin American and Caribbean Health Sciences Literature), ProQuest (Proquest Health and Medical Complete), Medline, SciELO (Scientific Electronic Library Online), and Scopus. The search equation with Medical Subject Headings (MeSH) descriptors was “Nurs* AND (handwashing OR hand hygiene) AND clinical trial”. The review was performed following the recommendations of the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: n = 17 clinical trials were included, with a total of 5747 nurses and nursing students. Strategies such as reminder sounds, practical simulations, videos, and audiovisual media improved handwashing compliance. Adherence overtime increased by up to 60%. The greatest effectiveness was related to the use of povidone–iodine, which reduced colony formation compared Hand hygiene teaching strategies among nursing staff: a systematic review to soap. Conclusions: The strategies that go beyond teaching techniques such as lectures may be more effective at increasing hand hygiene compliance. Combined approaches to learning/instruction improve user satisfaction by enabling self-management, flexibility, and repetition.

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.

Antibiotic susceptibility trend before and after long-term use of selective digestive decontamination: a 16 year ecological study

Objectives

The aim of this study was to compare antimicrobial susceptibility rates in a Spanish ICU before and after the introduction of selective digestive decontamination (SDD) and also to compare these with susceptibility data from other Spanish ICUs without SDD.

Methods

We performed a retrospective study in the ICU of the University Hospital of Alava, where SDD was implemented in 2002. The SDD protocol consisted of a 2% mixture of gentamicin, colistin and amphotericin B applied on the buccal mucosa and a suspension of the same drugs in the gastrointestinal tract; additionally, for the first 3 days, systemic ceftriaxone was administered. From 1998 to 2013 we analysed the susceptibility rates for 48 antimicrobial/organism combinations. Interrupted time series using a linear dynamic model with SDD as an intervention was used. Data from other ICUs were obtained from the ENVIN-HELICS national registry.

Results

Only amoxicillin/clavulanic acid against Escherichia coli and Proteus mirabilis, and a high concentration of gentamicin against Enterococcus faecalis, resulted in a significant decrease in the susceptibility rate after the implementation of SDD, with a drop of 20%, 27% and 32%, respectively. Compared with other Spanish ICUs without SDD, the susceptibility rate was higher in the ICU of our hospital in most cases. When it was lower, differences were <10%, except for a high concentration of streptomycin against Enterococcus faecium, for which the difference was 19%.

Conclusions

No relevant changes in the overall susceptibility rate after the implementation of SDD were detected. Susceptibility rates were not lower than those in the Spanish ICUs without SDD.

Susceptibility of Pseudomonas aeruginosa and antimicrobial activity using PK/PD analysis: an 18-year surveillance study

INTRODUCTION

We analysed the changes in the susceptibility of Pseudomonas aeruginosa to antimicrobials over an 18-year period (2000-2017) in order to evaluate the adequacy of the antimicrobial therapy against this organism in patients admitted in a tertiary Spanish hospital (excluding the intensive care unit). In addition, the antimicrobial activity was evaluated using pharmacokinetic/pharmacodynamic (PK/PD) criteria as a microbiological surveillance tool.

METHODS

Susceptibility was studied according to the Clinical and Laboratory Standards Institute breakpoints. Monte Carlo simulations were conducted to calculate the cumulative fraction of response (CFR). Linear regression analysis was applied to determine the trends in susceptibility and in the CFR.

RESULTS

In 2017, susceptibility rates were: amikacin, penicillins and cephalosporins ≥85%, tobramycin 76%, meropenem 75% and gentamicin, imipenem and fluoroquinolones <70%. PK/PD analyses was able to identify changes in antimicrobial activity not detected by only assessing MICs; meropenem administered in extended infusion attained a CFR >90%, ceftazidime, piperacillin/tazobactam and imipenem provided CFRs between 80-90%, all of them administered at the highest doses.

CONCLUSIONS

Analysis of susceptibility and PK/PD modelling, should be considered together to select the most appropriate antimicrobial drug and dosage regimen. Empirical antipseudomonal therapy would vary considerably if both microbiological surveillance tools were considered. In this study, the PK/PD analysis made it possible to preserve the therapeutic value of antimicrobials with low susceptibility rates, such as carbapenems, and the selection of the most effective antimicrobials among those with high rates of susceptibility.

Devising negative pressure within intercuff space reduces microaspiration

Background

Microaspiration past the tracheal tube cuffs causes ventilator-associated pneumonia. The objective of the current study was to evaluate whether creating negative pressure between the tracheal double cuffs could block the fluid passage past the tracheal tube cuffs.

Methods

A new negative pressure system was devised between the double cuffs through a suction hole in the intercuff space. Blue-dyed water was instilled above the cuff at negative suction pressures of − 54, − 68, − 82, − 95, − 109, − 122, and − 136 cmH₂O, and the volume leaked was measured in an underlying water trap after 10 min. Leakage tests were also performed during positive pressure ventilation, and using higher-viscosity materials. The actual negative pressures delivered at the hole of double cuffs were obtained by placing microcatheter tip between the intercuff space and the artificial trachea.

Results

No leakage occurred past the double cuff at − 136 cmH₂O suction pressure at all tracheal tube cuff pressures. The volume leaked decreased significantly as suction pressure increased. When connected to a mechanical ventilator, no leakage was found at − 54 cmH₂suction pressure. Volume of the higher-viscosity materials (dynamic viscosity of 63–108 cP <cP> and 370–430 cP) leaked was small compared to that of normal saline (0.9–1.1 cP). The pressures measured in the intercuff space corresponded to 3.8–5.9% of those applied.

Conclusions

A new prototype double cuff with negative pressure in the intercuff space completely prevented water leakage. The negative pressure transmitted to the tracheal inner wall was a small percentage of that applied.

Pharmacokinetic/pharmacodynamic analysis as a tool for surveillance of the activity of antimicrobials against Pseudomonas aeruginosa strains isolated in critically ill patients

INTRODUCTION

To evaluate the changes in the susceptibility of Pseudomonas aeruginosa over time (2000-2017) against antimicrobials used in an intensive care unit of a Spanish tertiary hospital, and to compare them with the antimicrobial activity considering theoretical pharmacokinetic/pharmacodynamic (PK/PD) criteria. The influence of the method for handling duplicate isolates to quantify susceptibility rates was also evaluated.

METHODS

The susceptibility was studied considering the Clinical and Laboratory Standards Institute (CLSI) breakpoints. Monte Carlo simulations were conducted to calculate the cumulative fraction of response (CFR). Linear regression analysis was applied to determine the trends in susceptibility and in the CFR.

RESULTS

A significant decrease in the susceptibility to gentamicin and imipenem was observed, and more recently the highest percentages of susceptible strains were found for amikacin, cephalosporins and piperacillin/tazobactam (>80%). The probability of success of an empiric treatment or CFR for most of the evaluated antimicrobials was lower than 70% during the last two-year period. Only meropenem provided high probabilities (>90%) to achieve the PK/PD target. Cephalosporins provided moderate probabilities (>80%) although for ceftazidime, the highest dose (2g/8h) was required. Moreover, a significant decrease in the CFR trend for ciprofloxacin, imipenem and levofloxacin was observed.

CONCLUSIONS

Both susceptibility rates and CFR values have to be considered together to optimize the antimicrobial dose regimen for clinical making-decisions. They are complementary tools and, they should be used jointly in surveillance programmes. In fact, susceptibility data are not always useful to detect changes in the CFR. No relevant differences were observed among the methods for handling repeated isolates.

Oropharyngeal antisepsis in the critical patient and in the patient subjected to mechanical ventilation

Lower respiratory tract infections in the intubated patient constitute a serious health problem due to their associated morbidity and mortality. Microaspiration of the buccopharyngeal secretions is the main physiopathological mechanism underlying the development of pneumonia and tracheobronchitis in intubated patients. All care bundles designed to prevent these infections include the use of antiseptics to reduce buccopharyngeal colonization. Chlorhexidine is the antiseptic most frequently assessed in clinical trials and meta-analyses that conclude that oral hygiene with chlorhexidine reduces the incidence of ventilator-associated pneumonia - maximum effectiveness being achieved when the product is administered at a concentration of 2%. However, 2meta-analyses have warned of a possible increase in mortality when chlorhexidine is used as an oral antiseptic. We therefore recommend its use but with extreme caution during application in order to avoid aspiration of the antiseptic. This article is part of a supplement entitled "Antisepsis in the critical patient", which is sponsored by Becton Dickinson.

Subglottic secretion drainage for ventilator-associated pneumonia prevention: an underused efficient measure

Subglottic secretion drainage (SSD) is one of the recommended strategies to prevent ventilator-associated pneumonia (VAP) with a high level of evidence, especially regarding early-onset pneumonia. All meta-analysis found that the use of SSD reduces VAP occurrence with a relative risk (RR) reduction of 45%. In some of them, SSD reduces the duration of mechanical ventilation (MV) but without beneficial effect on intensive care unit (ICU) or hospital mortality. In spite of the edited recommendations, SSD has not been widely implemented in ICUs and remains underused. Several factors could account for this: doubts on the innocuousness of using SSD, persisting reservations on the SSD effect on other outcomes than VAP, a high variability in the volume of secretions suctioned between patients and, for each individual patient, during the period of MV and the initial increased expense of the specific endotracheal tubes (ETs) allowing SSD which limits the availability of these devices.

"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.

Influence of subglottic secretion drainage on the microorganisms of ventilator associated pneumonia: A meta-analysis for subglottic secretion drainage

BACKGROUND

The influence of the subglottic secretion drainage (SSD) on the microorganisms of ventilator associated pneumonia (VAP) is still unclear.A meta-analysis focusing on the influence of the SSD on the microorganisms of VAP.

METHODS

A comprehensive search was conducted through the online studies of PubMed, Embase, Cochrane Library, Google scholar, CNKI (China National Knowledge Infrastructure), and VIPI (Database for Chinese Technical Periodicals) using specific search terms.Included studies were randomized controlled trials (RCTs) that compare the microorganisms of VAP between SSD and standard endotracheal tube care in mechanically ventilated adults.

RESULTS

Nine RCTs were eligible. There was no significant difference in the rate of VAP caused by nonfermentative bacteria and enterobacteria between SSD group and control group (OR = 0.73, 95%CI, 0.53-1.01; P = .06). The episodes of VAP caused by Gram-positive cocci and Haemophilus influenzae organisms were lower in the SSD group (OR = 0.29, 95%CI, 0.18-0.48; P<0.00001). Less mean volume of SSD daily was observed in VAP group (OR = -16.97, 95%CI, -29.87-4.08; P = .010).

CONCLUSION

We found SSD to be associated with significant decreases in VAP caused by Gram-positive cocci and H influenzae organisms but no significant differences in VAP caused by nonfermentative bacteria and enterobacteria. Less mean volume of SSD daily was observed in VAP group.

Incorporation of point-of-care ultrasound into morning round is associated with improvement in clinical outcomes in critically ill patients with sepsis

OBJECTIVES

Point-of-care ultrasound (POCUS) has been widely used in the intensive care unit (ICU). However, it is largely unknown whether the use of POCUS is associated with improved patient-important outcomes. The study aimed to investigate whether incorporation of POCUS during morning round on a routine basis was able to improve clinical outcomes in critically ill patients with sepsis.

DESIGN

It was a prospective observational study.

SETTING

A tertiary care emergency intensive care unit.

PATIENTS

All patients admitted to the emergency ICU from January 2016 to December 2017 were screened for potential eligibility. Sepsis was defined as infection plus signs of organ dysfunction.

INTERVENTION

The intervention group incorporated POCUS during morning round on a routine basis, and a checklist was developed to improve the compliance. The control group did not have the mandates to perform POCUS during morning round, but could use POCUS when necessary.

MEASUREMENTS

Clinical outcomes of mortality, length of stay in ICU, durations of vasopressors and mechanical ventilation were compared between the intervention and control groups. Multivariable regression model was employed to adjust for confounding factors.

MAIN RESULTS

A total of 129 subjects, including 88 in the control group and 41 in the intervention group, were included for analysis. Univariate analysis showed that the intervention group had shorter durations of mechanical ventilation (MV) (4.5 ± 1.2 vs. 5.7 ± 1.0 days; p = 0.034) and more negative fluid balance (-143 vs. 48 ml/24 h; p = 0.003) on day 3. In multivariable model, routine incorporation of POCUS was associated with lower risk of prolonged (>7 days) ICU stay (OR: 0.39, 95% CI: 0.29-0.88; p = 0.029).

CONCLUSIONS

The study showed that incorporation of POCUS during morning round on a routine basis was associated with shortened duration of MV and length of stay in ICU. The possible mechanism underlying the relationship may be via reduced fluid administration. Future randomized controlled trials are needed to validate current findings.