What is new in the prevention of nosocomial pneumonia in the ICU?

Antimicrobial Resistance in Ventilator-Associated Pneumonia: Predictive Microbiology and Evidence-Based Therapy

Ventilator-associated pneumonia (VAP) is a serious intensive care unit (ICU)-related infection in mechanically ventilated patients that is frequent, as more than half of antibiotics prescriptions in ICU are due to VAP. Various risk factors and diagnostic criteria for VAP have been referred to in different settings. The estimated attributable mortality of VAP can go up to 50%, which is higher in cases of antimicrobial-resistant VAP. When the diagnosis of pneumonia in a mechanically ventilated patient is made, initiation of effective antimicrobial therapy must be prompt. Microbiological diagnosis of VAP is required to optimize timely therapy since effective early treatment is fundamental for better outcomes, with controversy continuing regarding optimal sampling and testing. Understanding the role of antimicrobial resistance in the context of VAP is crucial in the era of continuously evolving antimicrobial-resistant clones that represent an urgent threat to global health. This review is focused on the risk factors for antimicrobial resistance in adult VAP and its novel microbiological tools. It aims to summarize the current evidence-based knowledge about the mechanisms of resistance in VAP caused by multidrug-resistant bacteria in clinical settings with focus on Gram-negative pathogens. It highlights the evidence-based antimicrobial management and prevention of drug-resistant VAP. It also addresses emerging concepts related to predictive microbiology in VAP and sheds lights on VAP in the context of coronavirus disease 2019 (COVID-19).

Barriers to compliance with evidence-based guidelines for ventilator-associated pneumonia among critical care nurses: A scoping review

Background: Healthcare organizations provide evidence-based guidelines designed to support nurses in preventing ventilator-associated pneumonia (VAP) in intensive care units (ICUs), but there are barriers to compliance with such guidelines. This review explicitly explored evidence of compliance barriers among critical care nurses. Methods: A systematic search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EBSCO databases for relevant English-language studies published between January 2003 and June 2022, focused on barriers to nursing compliance with VAP prevention guidelines. Data was reported according to the Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMAScR) guidelines.  Results: 230 publications were screened, resulting in 53 full-text articles being retrieved after removing duplicates, of which 13 relevant to the aims of the review and meeting the inclusion criteria were included for data extraction. One was a qualitative study, while the remainder were quantitative. Simple descriptive content analysis identified the barriers to critical care nurses’ compliance with VAP prevention guidelines, and categorized them as: (1) work environment barriers (e.g., lack of equipment and supplies; lack of staff and time; lack of educational support; and ineffective supportive system); (2) nurse-related barriers (limited personal competencies); and (3) situation-related barriers (patient health, discomfort, and adverse events). Conclusions: This review revealed important evidence on barriers to VAP prevention guidelines compliance. Nurses are challenged mainly by work-environmental barriers along, with the presence of nurse and situational barriers. It is evident from the findings that further qualitative and mixed-methodology follow-up studies are recommended to further explore the issues in depth.  Healthcare leaders must be aware of these barriers and integrate work policies that assist in overcoming them, to increase compliance.

Barriers to compliance with evidence-based guidelines for ventilator-associated pneumonia among critical care nurses: A scoping review

Background: Healthcare organizations provide evidence-based guidelines designed to support nurses in preventing ventilator-associated pneumonia (VAP) in intensive care units (ICUs), but there are barriers to compliance with such guidelines. This review explicitly explored evidence of compliance barriers among critical care nurses. Methods: A systematic search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EBSCO databases for relevant English-language studies published between January 2003 and June 2022, focused on barriers to nursing compliance with VAP prevention guidelines. Data was reported according to the Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMAScR) guidelines.  Results: 230 publications were screened, resulting in 53 full-text articles being retrieved after removing duplicates, of which 13 relevant to the aims of the review and meeting the inclusion criteria were included for data extraction. One was a qualitative study, while the remainder were quantitative. Simple descriptive content analysis identified the barriers to critical care nurses’ compliance with VAP prevention guidelines, and categorized them as: (1) work environment barriers (e.g., lack of equipment and supplies; lack of staff and time; lack of educational support; and ineffective supportive system); (2) nurse-related barriers (limited personal competencies); and (3) situation-related barriers (patient health, discomfort, and adverse events). Conclusions: This review revealed important evidence on barriers to VAP prevention guidelines compliance. Nurses are challenged mainly by work-environmental barriers along, with the presence of nurse and situational barriers. It is evident from the findings that further qualitative and mixed-methodology follow-up studies are recommended to further explore the issues in depth.  Healthcare leaders must be aware of these barriers and integrate work policies that assist in overcoming them, to increase compliance.

Comparison of Infectious Complications after Surgical Fixation versus Epidural Analgesia for Acute Rib Fractures

Background: Surgical stabilization of rib fractures (SSRF) is associated with decreased mortality and respiratory complications. Patients who are not offered SSRF are often treated with epidural analgesia (EA) to reduce pain and improve pulmonary mechanics. We sought to compare infectious complications in patients undergoing either SSRF or EA. We hypothesized that infectious complications are equivalent between the two treatment groups. Patients and Methods: We performed a retrospective cohort study of adult trauma patients with acute rib fractures within the Trauma Quality Improvement Program (TQIP) 2017 dataset and used International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify patients who underwent SSRF or EA. We excluded patients who received both treatments in the same admission. Our primary outcome was the development of sepsis. Secondary outcomes were specific infections including ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and central line-associated blood stream infections (CLABSI). Multiple logistic regression analyses were used to adjust for age, injury severity score (ISS), chest Abbreviated Injury Scale (AIS), flail chest, traumatic brain injury (TBI), and comorbidities. Results: We identified 2,252 and 1,299 patients who underwent SSRF and EA, respectively. Patients with SSRF were younger with higher ISS and longer length of stay (LOS). There was no difference in mortality, however, SSRF had higher rate of sepsis (1.6% vs. 0.5%; p = 0.001), VAP (5.1% vs. 0.9%; p < 0.001), CAUTI (1.7% vs. 0.5%; p = 0.001), and CLABSI (0.2% vs. 0%; p = 0.05). On multiple regression, SSRF was associated with higher odds of sepsis (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.04-6.63), CAUTI (OR, 2.96; 95% CI, 1.11-7.88), and VAP (OR, 3.24; 95% CI, 1.73-6.06). Among those who developed sepsis, there was no significant difference in mortality or LOS between groups. Conclusions: Despite no difference in mortality, SSRF was associated with increased risk of septic complications in patients with rib fractures compared to epidural analgesia. Identifying, and addressing, risk factors of sepsis in this patient population is a critical performance improvement process to optimize outcomes without increased adverse events.

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.

COVID-19 ARDS: A Multispecialty Assessment of Challenges in Care, Review of Research, and Recommendations

Physicians and care providers are familiar with the management of ARDS, however, when it occurs as a sequalae of COVID-19, it has different features and there remains uncertainty on the consensus of management. To answer this question on how it compares and contrasts with ARDS from other causes, the authors reviewed the published literature and management guidelines as well as their own clinical experience while managing patients with COVID-19 ARDS. For research, a PubMed search was conducted on 01.04.2021 using the systematic review filter to identify articles that were published using MeSH terms COVID-19 and ARDS. Systematic reviews or meta-analyses were selected from a systematic search for literature containing diagnostic, prognostic and management strategies in MEDLINE/PubMed. Those were compared and reviewed to the existing practices by the various treating specialists and recommendations were made. Specifically, the COVID-19 ARDS, its risk factors and pathophysiology, lab diagnosis, radiological findings, rational of recommendation of drugs proposed so far, oxygenation and ventilation strategies and the psychological ramifications of the disease were. discussed. Because of the high mortality in mechanically ventilated patients, the above recommendations and findings direct the potential for improvement in the management of patients with COVID-19 ARDS.

Preventive Effect of Probiotics on Ventilator-Associated Pneumonia: A Meta-analysis of 2428 Patients

BACKGROUND

Researchers had contradictory conclusions about the role of probiotics in preventing ventilator-associated pneumonia (VAP), which has led to the controversial use of probiotics in mechanically ventilated patients.

OBJECTIVE

To explore the efficacy and safety of probiotics in preventing VAP.

METHODS

A literature search was conducted in 7 medical databases. Two investigators assessed literature quality independently and collected data. The primary outcome was the incidence of VAP. Secondary outcomes included 16 measures. Sensitivity analysis and subgroup and meta-regression analyses were performed to analyze the source of heterogeneity. P values <0.05 were considered statistically significant, and CIs were set at 95%. A random-effects model was set when I² <50%, otherwise a fixed-effects model was used.

RESULTS

A total of 20 randomized controlled studies with a total of 2428 patients were analyzed. Pooled results showed positive effects of probiotics on the reduction of VAP incidence (risk ratio [RR] = 0.672; P < 0.001; I² = 11.3%), length of ICU stay (WMD = -1.417; P = 0.012; I² = 90.7%), oropharyngeal (RR = 0.866; P = 0.031; I² = 12.4%) and gastric (RR = 0.645; P < 0.001; I² = 30.2%) colonization.

CONCLUSIONS AND RELEVANCE

Probiotics can reduce the incidence of VAP and reduce oropharyngeal and gastric bacterial colonization. The results also suggest that probiotics do not cause adverse effects.

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.

Ventilator-associated tracheobronchitis: an update

Ventilator-associated lower respiratory tract infection is one of the most frequent complications in mechanically ventilated patients. Ventilator-associated tracheobronchitis has been considered a disease that does not warrant antibiotic treatment by the medical community for many years. In the last decade, several studies have shown that tracheobronchitis could be considered an intermediate process that leads to ventilator-associated pneumonia. Furthermore, ventilator-associated tracheobronchitis has a limited impact on overall mortality but shows a significant association with increased patient costs, length of stay, antibiotic use, and duration of mechanical ventilation. Although we still need clear evidence, especially concerning treatment modalities, the present study on ventilator-associated tracheobronchitis highlights that there are important impacts of including this condition in clinical management and epidemiological and infection surveillance.

Structure and process associated with the efficiency of intensive care units in low-resource settings: An analysis of the CHECKLIST-ICU trial database

PURPOSE

Characteristics of structure and process impact ICU performance and the outcomes of critically ill patients. We sought to identify organizational characteristics associated with efficient ICUs in low-resource settings.

MATERIALS AND METHODS

This is a secondary analysis of a multicenter cluster-randomized clinical trial in Brazil (CHECKLIST-ICU). Efficient units were defined by standardized mortality ratio (SMR) and standardized resource use (SRU) lower than the overall medians and non-efficient otherwise. We used a regularized logistic regression model to evaluate associations between organizational factors and efficiency.

RESULTS

From 118 ICUs (13,635 patients), 47 units were considered efficient and 71 non-efficient. Efficient units presented lower incidence rates (median[IQR]) of central line-associated bloodstream infections (4.95[0.00-22.0] vs 6.29[0.00-25.6], p = .04), utilization rates of mechanical ventilation (0.41[0.07-0.73] vs 0.58[0.19-0.82], p < .001), central venous catheter (0.67[0.15-0.98] vs 0.78[0.33-0.98], p = .04), and indwelling urinary catheter (0.62[0.22-0.95] vs 0.76[0.32-0.98], p < .01) than non-efficient units. The reported active surveillance of ventilator-associated pneumonia (OR = 1.72; 95%CI, 1.16-2.57) and utilization of central venous catheters (OR = 1.94; 95%CI, 1.32-2.94) were associated with efficient ICUs.

CONCLUSIONS

In low-resource settings, active surveillance of nosocomial infections and the utilization of invasive devices were associated with efficiency, supporting the management and evaluation of performance indicators as a starting point for improvement in ICU.

National Trends in Timing of Death Among Patients With Septic Shock, 1994-2014

OBJECTIVES

To assess trends in timing of mortality among patients with septic shock.

DESIGN

Retrospective cohort study.

SETTING

Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project's National Inpatient Sample, 1994-2014.

PATIENTS

Hospitalized adults (≥ 18 yr) with International Classification of Diseases, 9th Edition, Clinical Modification codes consistent with septic shock; secondary analysis: adults with International Classification of Diseases, 9th Edition, Clinical Modification codes consistent with acute respiratory failure receiving invasive mechanical ventilation and patients with both septic shock and acute respiratory failure receiving invasive mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

From 1994 to 2014, 48-hour mortality rates decreased among patients with septic shock (21.2% to 10.8%) and septic shock with acute respiratory failure receiving invasive mechanical ventilation (19.1% to 13.4%) but increased among patients with acute respiratory failure receiving invasive mechanical ventilation (7.9% to 9.8%; p value for all trends, < 0.001). Three-to-14-day mortality decreased among patients with septic shock (22.1% to 15.5%), septic shock with acute respiratory failure receiving invasive mechanical ventilation (28.7% to 22.4%) and acute respiratory failure receiving invasive mechanical ventilation (16.8% to 15.0%; p value for all trends, < 0.001). Mortality after 14 days decreased among all groups (septic shock: 12.6% to 6.7%; septic shock with acute respiratory failure receiving invasive mechanical ventilation: 20.3% to 11.3%; and acute respiratory failure receiving invasive mechanical ventilation: 12.7% to 5.8%; p value for all trends, < 0.001). Cox proportional hazard ratio for declining risk in mortality per year (adjusted for patient and hospital characteristics) was 0.96 (95% CI, 0.96-0.96) for septic shock, 0.97 (0.97-0.97) for acute respiratory failure receiving invasive mechanical ventilation and septic shock, and 0.99 (0.99-0.99) for acute respiratory failure receiving invasive mechanical ventilation.

CONCLUSIONS

Septic shock 48-hour, 3-14-day and greater than 14-day mortality declined markedly over two decades; in contrast, patients with acute respiratory failure only experienced marked decreases in greater than 14-day in-hospital mortality rates.

The utility of endotracheal aspirate bacteriology in identifying mechanically ventilated patients at risk for ventilator associated pneumonia: a single-center prospective observational study

Background

Ventilator-associated pneumonia (VAP) is a well-known, life-threatening disease that persists despite preventative measures and approved antibiotic therapies. This prospective observational study investigated bacterial airway colonization, and whether its detection and quantification in the endotracheal aspirate (ETA) is useful for identifying mechanically ventilated ICU patients who are at risk of developing VAP.

Methods

240 patients admitted to 3 ICUs at the Lahey Hospital and Medical Center (Burlington, MA) between June 2014 and June 2015 and mechanically ventilated for > 2 days were included. ETA samples and clinical data were collected. Airway colonization was assessed, and subsequently categorized into “heavy” and “light” by semi-quantitative microbiological analysis of ETAs. VAP was diagnosed retrospectively by the study sponsor according to a pre-specified pneumonia definition.

Results

Pathogenic bacteria were isolated from ETAs of 125 patients. The most common species isolated was S. aureus (56.8%), followed by K. pneumoniae, P. aeruginosa, and E. coli (35.2% combined). VAP was diagnosed in 85 patients, 44 (51.7%) with no bacterial pathogen, 18 associated with S. aureus and 18 Gram-negative-only cases, and 5 associated with other Gram-positive or mixed species. A higher proportion of patients who were heavily colonized with S. aureus developed VAP (32.4%) associated with S. aureus compared to those lightly colonized (17.6%). The same tendency was seen for patients heavily and lightly colonized with Gram-negative pathogens (30.0 and 0.0%, respectively). Detection of S. aureus in the ETA preceded S. aureus VAP by approximately 4 days, while Gram-negative organisms were first detected 2.5 days prior to Gram-negative VAP. VAP was associated with significantly longer duration of mechanical ventilation and hospitalization regardless of microbiologic cause when compared to patients who did not develop VAP.

Conclusions

The overall VAP rate was 35%. Heavy tracheal colonization supported identification of patients at higher risk of developing a corresponding S. aureus or Gram-negative VAP. Detection of bacterial ETA-positivity tended to precede VAP.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4367-7) contains supplementary material, which is available to authorized users.

Identification of respiratory microbiota markers in ventilator-associated pneumonia

PURPOSE

To compare bacteria recovered by standard cultures and metataxonomics, particularly with regard to ventilator-associated pneumonia (VAP) pathogens, and to determine if the presence of particular bacteria or microbiota in tracheal and oropharyngeal secretions during the course of intubation was associated with the development of VAP.

METHODS

In this case-control study, oropharyngeal secretions and endotracheal aspirate were collected daily in mechanically ventilated patients. Culture and metataxonomics (16S rRNA gene-based taxonomic profiling of bacterial communities) were performed on serial upper respiratory samples from patients with late-onset definite VAP and their respective controls.

RESULTS

Metataxonomic analyses showed that a low relative abundance of Bacilli at the time of intubation in the oropharyngeal secretions was strongly associated with the subsequent development of VAP. On the day of VAP, the quantity of human and bacterial DNA in both tracheal and oropharyngeal secretions was significantly higher in patients with VAP than in matched controls with similar ventilation times. Molecular techniques identified the pathogen(s) of VAP found by culture, but also many more bacteria, classically difficult to culture, such as Mycoplasma spp. and anaerobes.

CONCLUSIONS

Molecular analyses of respiratory specimens identified markers associated with the development of VAP, as well as important differences in the taxa abundance between VAP and controls. Further prospective trials are needed to test the predictive value of these markers, as well as the relevance of uncultured bacteria in the pathogenesis of VAP.

Application of a ventilator associated pneumonia prevention guideline and outcomes: A quasi-experimental study

OBJECTIVE

Ventilator associated pneumonia is the most frequent health-care-associated infection in Intensive Care Units, causing increased antibiotic consumption and resistance, length of stay, plus multiple health and economic costs. The aim of the study was to assess whether a customised guideline implementation would improve ventilator-associated pneumonia incidence and associated intensive care outcomes.

DESIGN

This was a quasi-experimental, before-after study consisting of pre-intervention, intervention and post-intervention periods.

SETTING

Three intensive care units at a well-known Portuguese hospital centre.

INTERVENTION

A set of eight recommendations was implemented after a guideline adaptation process.

PATIENTS

Adult patients admitted to the intensive care units over the study periods, aged 18 years or older and under invasive ventilation through an endotracheal tube or tracheostomy cannula.

MEASUREMENTS AND MAIN RESULTS

Data related to patient characterisation, guideline compliance and health outcomes were analysed. From a population of 1970 patients, a study sample of 828 was studied. Compliance with the recommendations was high. We identified a significant reduction in the incidence of ventilator-associated pneumonia in two of the units (p = 0.020 and p = 0.001) and a reduction in duration of invasive ventilation, intensive care unit length of stay and mortality in all the three units. We found associations between some recommendations and the implementation of the set of recommendations and intensive care unit length of stay, duration of invasive ventilation and mortality.

CONCLUSION

The implementation of an evidence-based, locally customised guideline may improve ventilator associated pneumonia incidence and several outcomes.

Ventilator-associated pneumonia in neonates and children: a systematic analysis of diagnostic methods and prevention

AIM

While ventilator-associated pneumonia (VAP) remains frequent in Pediatric ICU, there is no gold standard for diagnosis.

METHODOLOGY

We conducted a systematic PUBMED analysis (January 1990-January 2017) searching original, full-length studies addressing only pediatric patients; for VAP diagnosis, only those comparing different diagnostic methods and for VAP prevention those implementing preventive measures.

RESULTS

Among 367 articles, 17 and 16 were analyzed for diagnosis and prevention, respectively. For diagnosis, 13 studies used CDC criteria; whereas, 14 assessed algorithms: clinical pulmonary index score, ventilator-associated events and biomarkers. Among five randomized trials assessing preventive strategies one found a role of probiotics. Ventilator-care bundles reduced VAP rates.

CONCLUSION

Absence of diagnostic gold standard impedes comparison of current approaches and preventive strategies.

Preventing ventilator-associated pneumonia-a mixed-method study to find behavioral leverage for better protocol adherence

OBJECTIVE

Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence.

DESIGN

Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs).

SETTING

The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.Patients and participantsAdherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians.

RESULTS

Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%-31%); oral care at 41% (95% CI, 36%-45%); sedation interruption at 81% (95% CI, 74%-85%); and subglottic suctioning at 88% (95% CI, 83%-92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component 'reflective motivation' (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to 'physical capability' (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, 'restructuring environment' and 'enabling HCP') emerged as means to overcome these barriers.

CONCLUSIONS

Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts.

Impact of a VAP bundle in Belgian intensive care units

Background

In order to decrease the incidence of ventilator-associated pneumonia (VAP) in Belgium, a national campaign for implementing a VAP bundle involving assessment of sedation, cuff pressure control, oral care with chlorhexidine and semirecumbent position, was launched in 2011–2012. This report will document the impact of this campaign.

Methods

On 1 day, once a year from 2010 till 2016, except in 2012, Belgian ICUs were questioned about their ventilated patients. For each of these, data about the application of the bundle and the possible treatment for VAP were recorded.

Results

Between 36.6 and 54.8% of the 120 Belgian ICUs participated in the successive surveys. While the characteristics of ventilated patients remained similar throughout the years, the percentage of ventilated patients and especially the duration of ventilation significantly decreased before and after the national VAP bundle campaign. Ventilator care also profoundly changed: Controlling cuff pressure, head positioning above 30° were obtained in more than 90% of cases. Oral care was more frequently performed within a day, using more concentrated solutions of chlorhexidine. Subglottic suctioning also was used but in only 24.7% of the cases in the last years. Regarding the prevalence of VAP, it significantly decreased from 28% of ventilated patients in 2010 to 10.1% in 2016 (p ≤ 0.0001).

Conclusion

Although a causal relationship cannot be inferred from these data, the successive surveys revealed a potential impact of the VAP bundle campaign on both the respiratory care of ventilated patients and the prevalence of VAP in Belgian ICUs encouraging them to follow the guidelines.