Effectiveness of an Educational Program to Reduce Ventilator-Associated Pneumonia in a Tertiary Care Center in Thailand: A 4-Year Study

Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay

Could rebound explain the paradoxical lack of prevention effect against Staphylococcus aureus blood stream infections (BSIs) with antibiotic-based decontamination intervention (BDI) methods among studies of ICU patients within the literature? Two meta-regression models were applied, each versus the group mean length of stay (LOS). Firstly, the prevention effects against S. aureus BSI [and S. aureus VAP] among 136 studies of antibiotic-BDI versus other interventions were analyzed. Secondly, the S. aureus BSI [and S. aureus VAP] incidence in 268 control and intervention cohorts from studies of antibiotic-BDI versus that among 165 observational cohorts as a benchmark was modelled. In model one, the meta-regression line versus group mean LOS crossed the null, with the antibiotic-BDI prevention effect against S. aureus BSI at mean LOS day 7 (OR 0.45; 0.30 to 0.68) inverted at mean LOS day 20 (OR 1.7; 1.1 to 2.6). In model two, the meta-regression line versus group mean LOS crossed the benchmark line, and the predicted S. aureus BSI incidence for antibiotic-BDI groups was 0.47; 0.09-0.84 percentage points below versus 3.0; 0.12-5.9 above the benchmark in studies with 7 versus 20 days mean LOS, respectively. Rebound within the intervention groups attenuated and inverted the prevention effect of antibiotic-BDI against S. aureus VAP and BSI, respectively. This explains the paradoxical findings.

Infection-Related Ventilator-Associated Complication and Possible Ventilator-Associated Pneumonia among Mechanically Ventilated Patients of Adult Medical and Surgical Intensive Care Units

Objective An observational study was conducted to evaluate (1) the incidence rates of infection-related ventilator-associated complication (IVAC) and possible ventilator-associated pneumonia (PVAP) among mechanically ventilated patients of adult medical and surgical intensive care units (ICUs) and (2) the pathogen distribution in patients with PVAP.

Materials and Methods The IVAC and PVAP rates of medical and surgical ICUs, between July 1, 2017, and June 30, 2021, per 1,000 mechanical ventilator (MV) days were calculated. The significance of difference in IVAC and PVAP rates between medical and surgical ICUs was calculated. The level of significance was set at less than 0.05.

Results MV utilization ratios of adult medical and surgical ICUs were 0.32 and 0.26, respectively (p < 0.001). About 8 and 7 episodes of IVAC and 14 and 6 episodes of PVAP were reported from adult medical and surgical ICUs, accounting for IVAC rates of 3.17 and 1.8 per 1,000 MV (p > 0.05) and PVAP rates of 2.46 and 1.59 per 1,000 MV days in medical and surgical ICUs, respectively (p > 0.05). Acinetobacter baumannii complex either singly or in combination was isolated in 11/20 PVAP cases.

Conclusion IVAC and PVAP were more in medical compared with surgical ICUs. The most common pathogen in patients with PVAP was A. baumannii complex. More studies are warranted to monitor the significance of ventilator-associated event on patient outcomes.

Assessment of knowledge and compliance to evidence-based guidelines for VAP prevention among ICU nurses in Tanzania

BACKGROUND

Implementation of evidence-based guidelines (EBGs) related to VAP is an effective measure for the prevention of ventilator-associated pneumonia (VAP). While low knowledge regarding the EBGs related to VAP prevention among ICU nurses is still a major concern among nurses in ICUs globally, the situation in Tanzania is scarcely known. This study aimed to assess the ICU nurses' knowledge, compliance, and barriers toward evidence-based guidelines for the prevention of VAP in Tanzania.

METHODS

A cross-sectional study, involving ICU nurses of major hospitals in Tanzania, was conducted. A structured questionnaire was administered among 116 ICU nurses. Data analysis included descriptive statistics and the independent sample t-test.

RESULTS

The mean knowledge score was 3.86(SD = 1.56), based on ten questions (equivalent to 38.6%). Nurses with a degree or higher level of nursing education performed significantly better than the nurses with a diploma or lower level of nursing education (p = 0.004). The mean self-reported compliance score for EBGs for the prevention of VAP was 15.20 (SD = 0.93) which is equivalent to 60.8% based on 25 questions. The main barriers to the implementation of EBGs for VAP prevention were lack of skills (96.6%), lack of adequate staff (95.5%), and lack of knowledge (79.3%).

CONCLUSION

Considering the severity and impact of VAP, and the higher risks of HAIs in resource-limited countries like Tanzania, the lower level of knowledge and compliance implies the need for ongoing educational interventions and evaluation of the implementation of the EBGs for VAP prevention by considering the local context.

Knowledge of infection prevention and control among healthcare workers and factors influencing compliance: a systematic review

BACKGROUND

Knowledge of infection prevention and control (IPC) procedures among healthcare workers (HCWs) is crucial for effective IPC. Compliance with IPC measures has critical implications for HCWs safety, patient protection and the care environment.

AIMS

To discuss the body of available literature regarding HCWs' knowledge of IPC and highlight potential factors that may influence compliance to IPC precautions.

DESIGN

A systematic review. A protocol was developed based on the Preferred Reporting Items for Systematic reviews and Meta-Analysis [PRISMA] statement.

DATA SOURCES

Electronic databases (PubMed, CINAHL, Embase, Proquest, Wiley online library, Medline, and Nature) were searched from 1 January 2006 to 31 January 2021 in the English language using the following keywords alone or in combination: knowledge, awareness, healthcare workers, infection, compliance, comply, control, prevention, factors. 3417 papers were identified and 30 papers were included in the review.

RESULTS

Overall, the level of HCW knowledge of IPC appears to be adequate, good, and/or high concerning standard precautions, hand hygiene, and care pertaining to urinary catheters. Acceptable levels of knowledge were also detected in regards to IPC measures for specific diseases including TB, MRSA, MERS-CoV, COVID-19 and Ebola. However, gaps were identified in several HCWs' knowledge concerning occupational vaccinations, the modes of transmission of infectious diseases, and the risk of infection from needle stick and sharps injuries. Several factors for noncompliance surrounding IPC guidelines are discussed, as are recommendations for improving adherence to those guidelines.

CONCLUSION

Embracing a multifaceted approach towards improving IPC-intervention strategies is highly suggested. The goal being to improve compliance among HCWs with IPC measures is necessary.

Risk factors of ventilator-associated pneumonia in elderly patients receiving mechanical ventilation

Purpose: The aim of this study was to verify the potential risk factors of ventilator-associated pneumonia (VAP) in elderly Chinese patients receiving mechanical ventilation (MV). The secondary aim of this study was to present logistical regression prediction models of VAP occurrence in elderly Chinese patients receiving MV. Methods: Patients (aged 80 years or above) receiving MV for ≥48 h were enrolled from the Chinese People's Liberation Army (PLA) General Hospital from January 2011 to December 2015. A chi-squared test and Mann-Whitney U-test were used to compare the data between participants with VAP and without VAP. Univariate logistic regression models were performed to explore the relationship between risk factors and VAP. Results: A total of 901 patients were included in the study, of which 156 were diagnosed as VAP (17.3%). The incidence density of VAP was 4.25/1,000 ventilator days. Logistic regression analysis showed that the independent risk factors for elderly patients with VAP were COPD (OR =1.526, P < 0.05), intensive care unit (ICU) admission (OR=1.947, P < 0.01), the MV methods (P < 0.023), the number of antibiotics administered (OR=4.947, P < 0.01), the number of central venous catheters (OR=1.809, P < 0.05), the duration of indwelling urinary catheter (OR=1.805, P < 0.01) and the use of corticosteroids prior to MV (OR=1.618, P < 0.05). Logistic regression prediction model of VAP occurrence in the Chinese elderly patients with mechanical ventilation:L o g i t   P = - 6 . 468 + 0 . 423 X 1 + 0 . 666 X 2 + 0 . 871 X 3 + - 0 . 501 X 5 + 0 . 122 X 6 + 0 . 593 X 7 + 0 . 590 X 8 + 1 . 599 X 9 . Conclusion: VAP occurrence is associated with a variety of controllable factors including the MV methods and the number of antibiotics administered. A model was established to predict VAP occurrence so that high-risk patients could be identified as early as possible.

A Systematic Review and Meta-analysis of Ventilator-associated Pneumonia in Adults in Asia: An Analysis of National Income Level on Incidence and Etiology

Background

Ventilator-associated pneumonia (VAP) is the commonest hospital-acquired infection (HAI) in intensive care. In Asia, VAP is increasingly caused by resistant gram-negative organisms. Despite the global antimicrobial resistance crisis, the epidemiology of VAP is poorly documented in Asia.

Methods

We systematically reviewed literature published on Ovid Medline, Embase Classic, and Embase from 1 January 1990 to 17 August 2017 to estimate incidence, prevalence, and etiology of VAP. We performed a meta-analysis to give pooled rates and rates by country income level.

Results

Pooled incidence density of VAP was high in lower- and upper-middle-income countries and lower in high-income countries (18.5, 15.2, and 9.0 per 1000 ventilator-days, respectively). Acinetobacter baumannii (n = 3687 [26%]) and Pseudomonas aeruginosa (n = 3176 [22%]) were leading causes of VAP; Staphylococcus aureus caused 14% (n = 1999). Carbapenem resistance was common (57.1%).

Conclusions

VAP remains a common cause of HAI, especially in low- and middle-income countries, and antibiotic resistance is high.

"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.

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review

BACKGROUND

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes.

AIMS

The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes.

METHODS

Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity.

RESULTS

Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay.

CONCLUSION

Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required.

RELEVANCE TO CLINICAL PRACTICE

Well-designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes.

World-Wide Variation in Incidence of Staphylococcus aureus Associated Ventilator-Associated Pneumonia: A Meta-Regression

Staphylococcus aureus (S. aureus) is a common Ventilator-Associated Pneumonia (VAP) isolate. The objective here is to define the extent and possible reasons for geographic variation in the incidences of S. aureus-associated VAP, MRSA-VAP and overall VAP. A meta-regression model of S. aureus-associated VAP incidence per 1000 Mechanical Ventilation Days (MVD) was undertaken using random effects methods among publications obtained from a search of the English language literature. This model incorporated group level factors such as admission to a trauma ICU, year of publication and use of bronchoscopic sampling towards VAP diagnosis. The search identified 133 publications from seven worldwide regions published over three decades. The summary S. aureus-associated VAP incidence was 4.5 (3.9–5.3) per 1000 MVD. The highest S. aureus-associated VAP incidence is amongst reports from the Mediterranean (mean; 95% confidence interval; 6.1; 4.1–8.5) versus that from Asian ICUs (2.1; 1.5–3.0). The incidence of S. aureus-associated VAP varies by up to three-fold (for the lowest versus highest incidence) among seven geographic regions worldwide, whereas the incidence of VAP varies by less than two-fold. Admission to a trauma unit is the most important group level correlate for S. aureus-associated VAP.

Surveillance of preventive measures for ventilator associated pneumonia (VAP) and its rate in Makkah Region hospitals, Saudi Arabia

BACKGROUND/AIM

The present study aimed to assess the VAP rate and to identify VAP prevention activities in public sector hospitals situated in the Makkah Region, Saudi Arabia (SA).

MATERIALS AND METHODS

In this cross-sectional study, the VAP data from 13 public sector hospitals were collected from January to December 2013 and analyzed using SPSS 16.

RESULTS

The overall VAP rate in Makkah Region hospitals was 6.89 cases per 1000 ventilator-days. There was a significant difference in VAP rate among the hospitals of the Makkah Region (P < 0.001). There was no significant difference in the VAP rate among hospitals, which were using only one, two, or all three VAP preventive approaches (P = 0.26) accredited by the Joint Commission International (JCI) and Central Board for Accreditation of Health Care Institution (CBAHI) (P = 0.12), and using the form in intensive care units (ICUs) (P = 0.85). There was a significant difference in the VAP rate among hospitals having different bed capacities (P < 0.001), data regularly collected (P = 0.03), and had a team to supervise the VAP project (P = 0.04).

CONCLUSION

The VAP rate in Makkah Region hospitals is 6.89 cases per 1000 ventilator-days.

Impact and feasibility of an emergency department-based ventilator-associated pneumonia bundle for patients intubated in an academic emergency department

BACKGROUND

Ventilator-associated pneumonia (VAP) has been linked to emergency department (ED) intubation and length of stay (LOS). We assessed VAP prevalence in ED intubated patients, feasibility of ED VAP prevention, and effect on VAP rates.

METHODS

This was a quality improvement initiative using a pre/post design. Phase 1 (PRE1) comprised patients before intensive care unit (ICU) bundle deployment. Phase 2 (PRE2) occurred after ICU but before ED deployment. Phase 3 (POST) included patients received VAP prevention starting at ED intubation. Log-rank test for equality and Cox regression using a Breslow method for ties were performed. Bundle compliance was reported as percentages. Number needed to treat (NNT) was calculated by ventilator day.

RESULTS

PRE1, PRE2, and POST groups were composed of 195, 192, and 153 patients, respectively, with VAP rates of 22 (11.3%), 11 (5.7%), and 6 (3.9%). Log-rank test showed significant reduction in VAP (χ² = 9.16, P = .0103). The Cox regression hazard ratio was 1.38 for the Clinical Pulmonary Infection Score (P = .001), and the hazard ratio was 0.26 for the VAP bundle (P = .005). Bundle compliance >50% for head-of-bed elevation, oral care, subglottic suctioning, and titrated sedation improved significantly with introduction of a registered nurse champion. NNT varied from 7 to 11.

CONCLUSIONS

VAP was common for ED intubated patients. ED-based VAP prevention is feasible. We demonstrate significant reduction in VAP rates, which should be replicated in a multicenter study.

Oral health and ventilator-associated pneumonia among critically ill patients: a prospective study

OBJECTIVE

To evaluate the association between oral health and ventilator-associated pneumonia (VAP) among critically ill patients.

METHODS

A prospective cohort study was conducted among 162 critically ill patients newly intubated and treated with mechanical ventilator in one tertiary hospital in Thailand. Oral health status was assessed using Oral Health Assessment Tool (OHAT), Plaque Index (PI), and number of teeth. VAP, defined as Clinical Pulmonary Infection Score >6, was assessed on Day 4 after intubation. Hazard ratios and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression adjusted for confounders.

RESULTS

Critically ill patients had deteriorating oral health status after intubation. Early-onset VAP developed in 69 patients (42.6%), with VAP incidence of 117 episodes per 1000 ventilator-days. Moderately unhealthy and unhealthy oral conditions based on OHAT scores were associated with a 2.92-fold (95% CI: 1.26-6.74) and 3.22-fold (95% CI: 1.34-7.76) increased risk of VAP. Patients with moderate-to-very poor oral hygiene assessed by PI had increased VAP risk of 1.66-folds (95% CI: 1.001-2.75). The number of teeth was not associated with VAP development.

CONCLUSIONS

There is a strong association between poor oral health and increased risk for early-onset VAP. Routine oral care possibly prevents VAP development among critically ill patients treated with mechanical ventilator.

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Infection control in the intensive care unit

It is critical for health care personnel to recognize and appreciate the detrimental impact of intensive care unit (ICU)-acquired infections. The economic, clinical, and social expenses to patients and hospitals are overwhelming. To limit the incidence of ICU-acquired infections, aggressive infection control measures must be implemented and enforced. Researchers and national committees have developed and continue to develop evidence-based guidelines to control ICU infections. A multifaceted approach, including infection prevention committees, antimicrobial stewardship programs, daily reassessments-intervention bundles, identifying and minimizing risk factors, and continuing staff education programs, is essential. Infection control in the ICU is an evolving area of critical care research.

Implementing quality improvement strategies to reduce healthcare-associated infections: A systematic review

BACKGROUND

Comprehensive incidence estimates indicate that 1.7 million healthcare-associated infections (HAIs) and 99,000 HAI-associated deaths occur in US hospitals. Preventing HAIs could save $25.0 to $31.5 billion. Identifying effective quality improvement (QI) strategies for promoting adherence to evidence-based preventive interventions could reduce infections.

METHODS

We searched MEDLINE, CINAHL, and EMBASE from 2006-2012 for English-language articles with ≥ 100 patients that described an implementation strategy to increase adherence with evidence-based preventive interventions and that met study design criteria. One reviewer abstracted and appraised study quality, with verification by a second. QI strategies included audit and feedback; financial incentives, regulation, and policy; organizational change; patient education; provider education; and provider reminder systems.

RESULTS

We evaluated data on HAIs from 30 articles reporting adherence and infection rates that accounted for confounding or secular trends. Many of the measures improved significantly, especially adherence. Results varied by QI strategy(s).

CONCLUSIONS

Moderate strength of evidence supports improvement in adherence and infection rates when audit and feedback plus provider reminder systems or audit and feedback alone is added to organizational change and provider education. Strength of evidence is low when provider reminder systems alone are added to organizational change and provider education. There were no studies on HAIs in nonhospital settings that met the selection criteria.

Differences in incidence and outcome of ventilator-associated pneumonia in surgical and medical ICUs in a tertiary hospital in China

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection in intensive care units (ICUs). The incidences and outcomes of VAP in a medical ICU (MICU) and a surgical ICU (SICU) were compared.

METHODS

A total of 329 patients admitted to the MICU or SICU who were mechanically ventilated for ≥48 h were included.

RESULTS

The incidence of VAP in the MICU was 25%, with 29.7 cases per 1000 ventilator days, and the incidence of VAP in the SICU was 26.7%, with 27.4 cases per 1000 ventilator days. In the MICU patients without VAP spent 6.0 days on the ventilator and those with VAP spent 8.5 days (P < 0.001); the length of stay (LOS) in the ICU was 9.0 days vs 14.0 days for patients without and with VAP, respectively (P < 0.001). The mortality in the MICU was 34.1% for patients without VAP vs 55.8% for those with VAP (P = 0.012), and 30-day mortalities were 31.8% and 41.9%, respectively (P = 0.228); 60-day mortalities were 34.1% and 53.5%, respectively (P = 0.024). In the SICU, patients without and with VAP were ventilated for 5.0 and 10.0 days, respectively (P < 0.001). The ICU LOS was 7.0 days for patients without VAP vs 15.0 days for patients with VAP (P < 0.001). The mortality rates of VAP-free and VAP-positive patients in the SICU were 38.9% and 54.5%, respectively (P = 0.076). The 30-day mortalities were 36.3% and 43.2% (P = 0.424), and 60-day mortalities were 38.9% and 50.0%, for patients without and with VAP, respectively (P = 0.061).

CONCLUSIONS

These data indicate that VAP prolonged time on ventilator and ICU stay in our institute and increased the mortality in the MICU. There were no differences in incidence of or mortality from VAP in the MICU and SICU.

Impact of education on ventilator-associated pneumonia in the intensive care unit

INTRODUCTION

Ventilator-associated pneumonia (VAP) is a common risk among critically ill ventilated patients. This study aimed to investigate the effects of nurse-led education on: (a) knowledge of and compliance with ventilator care bundle (VCB) practices among intensive care unit (ICU) nurses; and (b) reduction in the rates of VAP post intervention.

METHODS

A quasi-experimental design with pretest-posttest evaluation and observation was used to investigate nurses' knowledge of and compliance with VCB practices, and the incidence of VAP. The study was conducted among 71 nurses, and the intervention involved structured education on VAP and its prevention using VCB in an ICU setting. Data were analysed using descriptive and inferential statistics.

RESULTS

Nurse-led education significantly increased nurses' knowledge of (t[70] = -36.19; p < 0.001) and compliance with (t[65] = -21.41; p < 0.001) VCB practices. The incidence of VAP, which was 39 per 1,000 ventilator days during the two-month period before intervention, dropped to 15 per 1,000 ventilator days during the two-month period following intervention.

CONCLUSION

Our findings show that nurse-led education on VAP and VCB significantly increased knowledge of and compliance with VCB practices among ICU nurses, and was associated with a reduction in the incidence of VAP among intubated and mechanically ventilated ICU patients. Inclusion of recent knowledge and evidence-based VCB guidelines for VAP prevention when educating anaesthetists, nurses, physiotherapists and other healthcare providers in the critical care setting is recommended.

Prevention of nosocomial infections in developing countries, a systematic review

BACKGROUND

Prevention of nosocomial infection is key to providing good quality, safe healthcare. Infection control programmes (hand-hygiene campaigns and antibiotic stewardship) are effective in reducing nosocomial infections in developed countries. However, the effectiveness of these programmes in developing countries is uncertain.

OBJECTIVE

To evaluate the effectiveness of interventions for preventing nosocomial infections in developing countries.

METHODS

A systematic search for studies which evaluated interventions to prevent nosocomial infection in both adults and children in developing countries was undertaken using PubMed. Only intervention trials with a randomized controlled, quasi-experimental or sequential design were included. Where there was adequate homogeneity, a meta-analysis of specific interventions was performed using the Mantel-Haenzel fixed effects method to estimate the pooled risk difference.

RESULTS

Thirty-four studies were found. Most studies were from South America and Asia. Most were before-and-after intervention studies from tertiary urban hospitals. Hand-hygiene campaigns that were a major component of multifaceted interventions (18 studies) showed the strongest effectiveness for reducing nosocomial infection rates (median effect 49%, effect range 12.7-100%). Hand-hygiene campaigns alone and studies of antibiotic stewardship to improve rational antibiotic use reduced nosocomial infection rates in three studies [risk difference (RD) of -0.09 (95%CI -0.12 to -0.07) and RD of -0.02 (95% CI -0.02 to -0.01), respectively].

CONCLUSIONS

Multifaceted interventions including hand-hygiene campaigns, antibiotic stewardship and other elementary infection control practices are effective in developing countries. The modest effect size of hand-hygiene campaigns alone and negligible effect size of antibiotic stewardship reflect the limited number of studies with sufficient homogeneity to conduct meta-analyses.

Critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia--a survey study

OBJECTIVES

To explore critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia.

DESIGN

A quantitative cross-sectional survey.

METHODS

Two multiple-choice questionnaires were distributed to critical care nurses (n=101) in a single academic centre in Finland in the autumn of 2010. An independent-samples t-test was used to compare critical care nurses' knowledge and adherence within different groups. The principles of inductive content analysis were used to analyse the barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia.

RESULTS

The mean score in the knowledge test was 59.9%. More experienced nurses performed significantly better than their less-experienced colleagues (p=0.029). The overall, self-reported adherence was 84.0%. The main self-reported barriers towards evidence-based guidelines were inadequate resources and disagreement with the results as well as lack of time, skills, knowledge and guidance.

CONCLUSION

There is an ongoing need for improvements in education and effective implementation strategies.

CLINICAL IMPLICATIONS

The results could be used to inform local practice and stimulate debate on measures to prevent ventilator-associated pneumonia. Education, guidelines as well as ventilator bundles and instruments should be developed and updated to improve infection control.

National survey of Thai infection preventions in the era of patient safety

A national survey of infection preventionists was conducted in Thailand to assess career satisfaction, perceived barriers to implementing infection control practices and current sources of continuing education. Despite positive career satisfaction, several barriers were identified, including a lack of physicians to champion infection control efforts and difficulty remaining current with new evidence-based recommendations.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

Ventilator-associated complications, including infection-related complications: the way forward

Acute respiratory failure represents the most common condition requiring admission to an adult intensive care unit. Ventilator-associated pneumonia (VAP) has been used as a marker of quality for patients with respiratory failure. Hospital-based process-improvement initiatives to prevent VAP have been successfully used. The use of ventilator-associated complications (VACs) has been proposed as an objective marker to assess the quality of care for this patient population. The use of evidence-based bundles targeting the reduction of VACs, as well as the conduct of prospective studies showing that VACs are preventable complications, are reasonable first-steps in addressing this important clinical problem.

Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections in pediatric intensive care units (PICUs). Practice bundles have been shown to reduce VAP rates in PICUs in developed countries; however, the impact of a multidimensional approach, including a bundle, has not been analyzed in PICUs from developing countries.

METHODS

This was a before-after study to determine rates of VAP during a period of active surveillance without the implementation of the multidimensional infection control program (phase 1) to be compared with rates of VAP after implementing such a program, which included the following: bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices (phase 2). This study was conducted by infection control professionals applying the National Health Safety Network's definitions of health care-associated infections and the International Nosocomial Infection Control Consortium's surveillance methodology.

RESULTS

During the baseline period, we recorded a total of 5,212 mechanical ventilator (MV)-days, and during implementation of the intervention bundle, we recorded 9,894 MV-days. The VAP rate was 11.7 per 1,000 MV-days during the baseline period and 8.1 per 1,000 MV-days during the intervention period (relative risk, 0.69; 95% confidence interval, 0.5-0.96; P = .02), demonstrating a 31% reduction in VAP rate.

CONCLUSIONS

Our results show that implementation of the International Nosocomial Infection Control Consortium's multidimensional program was associated with a significant reduction in VAP rate in PICUs of developing countries.

Evaluation of emergency department evidence-based practices to prevent the incidence of ventilator-acquired pneumonia

Pathogens in the oropharynx may be transported to the lung parenchyma during intubation and cause ventilator-acquired pneumonia. This project evaluated 3 post intubation evidence-based practices in the emergency department: oral care, head-of-bed elevation, and suctioning above the endotracheal tube balloon. Ventilator-acquired pneumonia cases decreased 83% after implementing these practices. There is no need to wait for the patient to be admitted to intensive care to begin these evidence-based practices.

Impact of a region wide antimicrobial stewardship guideline on urinary tract infection prescription patterns

BACKGROUND

Fluoroquinolones are frequently prescribed for non complicated urinary tract infection treatments and have a negative ecological impact. We aimed to substitute them by antibiotics with narrower activity spectrum in order to preserve fluoroquinolone activity in complicated hospital infections.

OBJECTIVE

To assess the impact of a multi-modal approach that combines the dispatching of antibiotic prescription guidelines and voluntary attendance at educational sessions on general practitioners' (GP) antibiotic prescription habits.

SETTING

This study was led in Franche-Comté, a French eastern region, where GPs were given a guideline recommending a restricted use of fluoroquinolones for urinary tract infections.

METHOD

Segmented regression analysis of interrupted time series was used to assess changes in antibiotic prescription.

MAIN OUTCOME MEASURE

The antibiotic prescription data of nitrofurantoin, fosfomycin-trometamol and fluoroquinolones for women aged 15-65 years were obtained from the regional agency of health insurance.

RESULTS

Twenty months after intervention, the number of nitrofurantoin and fosfomycintrometamol prescriptions increased by 36.8% (95% CI: 30.6-42.2) and 28.5% (95% CI: 22.9-35.4), respectively, while that of norfloxacin decreased by 9.1% (95% CI: -15.3 to -3.5).

CONCLUSION

This study suggests that the dispatch of the guideline on urinary tract infection had a moderate impact on antibiotic prescriptions.

[Nursing care in the prevention of ventilator-associated pneumonia]

INTRODUCTION

Certain nursing interventions reduce the incidence of ventilator-associated pneumonia (VAP).

OBJECTIVES

a) to analyze in patients with more than 24 hours of invasive mechanical ventilation how frequently oral hygiene, oropharyngeal suction, turning and evaluation of the tolerance of enteral nutrition were performed according to established protocols; b) to record in these same patients endotracheal tube cuff pressures and the degrees of elevation of the head of the bed (HOB); c) to determine over the three months of the study the incidence density of VAP.

METHOD

This descriptive study was carried out in 26 patients. The nursing interventions of interest were recorded daily. Furthermore, endotracheal tube cuff pressures and the degrees of elevation of HOB were measured 3 times a day. Compliance with the established protocols was considered good when it reached ≥80%. Cases of VAP were determined using CDC criteria. The incidence density was calculated including all the patients (122) with mechanical ventilation during the study period.

RESULTS

Good compliance with the established protocols was achieved for oral hygiene in 23 patients, for oropharyngeal suction and for turning in 19 patients, and in all patients for the evaluation of the tolerance of enteral nutrition. In 214 measurements endotracheal tube cuff pressure was ≥ 20cm H20 and in 121 lower. In 79 measurements elevation of HOB was ≥30° and in 256 lower. The incidence density of VAP was 7.43/ 1.000 days of mechanical ventilation.

CONCLUSIONS

: For these nurse interventions aimed at preventing VAP, levels of compliance with established protocols were satisfactory. The incidence density of VAP was low and well within internationally established ranges. Nevertheless, the incidence of VAP could be further reduced with a better control of cuff pressures and by elevating the HOB to between 30° and 45°.

[Southern European intensive care nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia]

OBJECTIVES

To assess Southern European intensive care unit nurses' knowledge about evidence-based guidelines for the prevention of ventilator-associated pneumonia and to compare these findings with a pan-European perspective.

DESIGN

A sub-analysis from an observational study performed using a 9-questions, multiple-choice questionnaire performed during the period October 2006 - March 2007.

SETTING

Six Southern European countries, selected from 22 participant European countries.

PARTICIPANTS

Volunteer nurses from intensive care units.

RESULTS

3329 questionnaires were obtained, 1182 of them belonging to Southern European countries with a 75.8% response rate. Global average score was 45.1%, being it significantly better in the South of Europe (46.6%, P<.001). A linear multiple regression analysis showed that years of working experience (per class of increase) (B=0.154 ± (SD) 0.045) (95% CI (0.066-0.242))(p=0.001) and working in a smaller intensive care unit (B=-0.210 ± (SD) 0.059)((95% CI) -0.326-0.094)(P<.001) was independently associated with better test scores.

CONCLUSIONS

Southern European critical care nurses' knowledge about ventilator-associated pneumonia prevention is poor, but significantly better than in the pan-European countries.

Recognition and prevention of nosocomial pneumonia in the intensive care unit and infection control in mechanical ventilation

Nosocomial pneumonia (NP) is a difficult diagnosis to establish in the critically ill patient due to the presence of underlying cardiopulmonary disorders (e.g., pulmonary contusion, acute respiratory distress syndrome, atelectasis) and the nonspecific radiographic and clinical signs associated with this infection. Additionally, the classification of NP in the intensive care unit setting has become increasingly complex, as the types of patients who develop NP become more diverse. The occurrence of NP is especially problematic as it is associated with a greater risk of hospital mortality, longer lengths of stay on mechanical ventilation and in the intensive care unit, a greater need for tracheostomy, and significantly increased medical care costs. The adverse effects of NP on healthcare outcomes has increased pressure on clinicians and healthcare systems to prevent this infection, as well as other nosocomial infections that complicate the hospital course of patients with respiratory failure. This manuscript will provide a brief overview of the current approaches for the diagnosis of NP and focus on strategies for prevention. Finally, we will provide some guidance on how standardized or protocolized care of mechanically ventilated patients can reduce the occurrence of and morbidity associated with complications like NP.

Effectiveness of a catheter-associated bloodstream infection bundle in a Thai tertiary care center: a 3-year study

BACKGROUND

We sought to determine the long-term impact of "bundled" infection control interventions on the rates of catheter-associated bloodstream infection (CA-BSI) in a middle-income country.

SETTING

A 500-bed tertiary care center in Thailand.

METHODS

A 3-year, hospital-wide, prospective quasi-experimental study was conducted for 1 year before the intervention (period 1), 1 year after implementation of the CA-BSI bundle (period 2), and at a 1-year follow-up after the intervention with intensified hand hygiene promotion (period 3).

RESULTS

In period 1, 88 episodes of CA-BSI (14 cases per 1000 catheter-days) were recorded. During period 2, the CA-BSI rate decreased by 54.1 % (6.4 cases per 1000 catheter-days; P <.001). Compared with period 1 (8% adherence), hand hygiene adherence was improved in period 2 (24%; P <.001) and period 3 (54%; P <.001). The CA-BSI rate was further decreased by 78% (1.4 cases per 1000 catheter-days; P <.001) during period 3. Notably, no CA-BSIs were seen in 6 of the 12 months (50%) of period 3. Compared with period 1, the mean number of catheter-days was significantly reduced in period 2 (4.9 +/- 1.5 days; P <.001) and period 3 (4.1 +/- 1.1 days; P <.001).

CONCLUSION

Bundled infection control practices are feasible and effective in sustaining reduced incidence of CA-BSI in patients with central venous catheters in a resource-limited setting.

Successful prevention of ventilator-associated pneumonia in an intensive care setting

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections (HAIs) in critical care settings.

OBJECTIVE

Our objective was to examine the effect of a series of interventions, implemented in 3 different periods to reduce the incidence of VAP in an intensive care unit (ICU).

METHODS

A quasiexperimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed during different phases. From March 2001 to December 2002 (phase 1: P1), some Centers for Disease Control and Prevention (CDC) evidence-based practices were implemented. From January 2003 to December 2006 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and, from January 2007 to September 2008 (P3), we continued P2 interventions and implemented the Institute for Healthcare Improvement's ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions.

RESULTS

The incidence density of VAP in the ICU per 1000 patient-days was 16.4 in phase 1, 15.0 in phase 2, and 10.4 in phase 3, P=.05. Getting to zero VAP was possible only in P3 when compliance with all interventions exceeded 95%.

CONCLUSION

These results suggest that reducing VAP rates to zero is a complex process that involves multiple performance measures and interventions.

Ventilator-associated infection

PURPOSE OF REVIEW

Ventilator-associated pneumonia (VAP) is the most serious and controversial of the infections of the critically ill patient. The accuracy of standard methods of diagnosis remains under constant scrutiny, and at the same time there is increasing debate about whether it is a preventable disease. This review focuses on the pathophysiology of respiratory tract infection in the ventilated patient, and how the latest advances have grown from our current understanding of its pathogenesis.

RECENT FINDINGS

Data from many recent investigations have focused on the role of proximal airway infection, ventilator-associated tracheobronchitis (VAT), in respiratory tract infection. The goals of recent trials include reducing the morbidity associated with the progression of airway colonization to VAT or with the progression of VAT to VAP. Continuous subglottic secretion suctioning, innovative types of endotracheal tubes and targeted therapy for VAT in recent investigations have shown promise in improving clinical outcomes in the critically ill patient. However, even with diligent attention to all the modifiable risk factors for respiratory infection, complete elimination of VAT and VAP remains unlikely. As long as a patient requires an endotracheal tube that disturbs airway integrity, host defenses will be impaired, and resistant virulent organisms that result from our liberal use of systemic antibiotics will continue to challenge critical care specialists.

SUMMARY

This review will focus on: the current understanding of the pathogenesis of VAT and VAP, modifiable risk factors and new approaches to treatment, and bacterial resistance challenges.

Can outcome prediction data change patient outcomes and organizational outcomes?

PURPOSE OF REVIEW

Intensive care medicine consumes a high share of healthcare costs, and there is growing pressure to use the scarce resources efficiently. Accordingly, organizational issues and quality management have become an important focus of interest in recent years. Here, we will review current concepts of how outcome data can be used to identify areas requiring action.

RECENT FINDINGS

Using recently established models of outcome assessment, wide variability between individual ICUs is found, both with respect to outcome and resource use. Such variability implies that there are large differences in patient care processes not only within the ICU but also in pre-ICU and post-ICU care. Indeed, measures to improve the patient process in the ICU (including care of the critically ill, patient safety, and management of the ICU) have been presented in a number of recently published papers.

SUMMARY

Outcome assessment models provide an important framework for benchmarking. They may help the individual ICU to spot appropriate fields of action, plan and initiate quality improvement projects, and monitor the consequences of such activity.