Effectiveness of a Ventilator Care Bundle to Prevent Ventilator-Associated Pneumonia at the PICU: A Systematic Review and Meta-Analysis

Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events

INTRODUCTION

Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP.

AREAS COVERED

This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles.

EXPERT OPINION

Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.

Pediatric Ventilator-Associated Events Before and After a Multicenter Quality Improvement Initiative

Importance

Pediatric ventilator-associated events (PedVAEs, defined as a sustained worsening in oxygenation after a baseline period of stability or improvement) are useful for surveillance of complications from mechanical ventilation. It is unclear whether interventions to mitigate known risk factors can reduce PedVAE rates.

Objective

To assess whether adherence to 1 or more test factors in a quality improvement bundle was associated with a reduction in PedVAE rates.

Design, Setting, and Participants

This multicenter quality improvement study obtained data from 2017 to 2020 for patients who were mechanically ventilated and cared for in neonatal, pediatric, and cardiac intensive care units (ICUs). These ICUs were located in 95 hospitals participating in the Children's Hospitals' Solutions for Patient Safety (SPS) network in North America. Data analyses were performed between September 2021 and April 2023.

Intervention

A quality improvement bundle consisted of 3 test factors: multidisciplinary apparent cause analysis, daily discussion of extubation readiness, and daily discussion of fluid balance goals. This bundle was distributed to a subgroup of hospitals that volunteered to participate in a collaborative PedVAE prevention initiative under the SPS network guidance in July 2018.

Main Outcomes and Measures

Each SPS network hospital submitted monthly PedVAE rates from January 1, 2017, to May 31, 2020, and test factor data were submitted from July 1, 2018, to May 31, 2020. Analyses focused on hospitals that reliably submitted PedVAE rate data, defined as outcomes data submission through May 31, 2020, for at least 80% of the baseline and postbaseline periods.

Results

Of the 95 hospitals in the SPS network that reported PedVAE data, 21 were grouped in the Pioneer cohort and 74 in the non-Pioneer cohort. Only 12 hospitals (57%) from the 21 Pioneer hospitals and 33 (45%) from the 74 non-Pioneer hospitals were considered to be reliable reporters of outcome data. Among the 12 hospitals, the PedVAE rate decreased from 1.9 to 1.4 events per 1000 ventilator days (absolute rate difference, -0.6; 95% CI, -0.5 to -0.7; P < .001). No significant change in the PedVAE rate was seen among the 33 hospitals that reliably submitted PedVAE rates but did not implement the bundle. Of the 12 hospitals, 3 that reliably performed daily discussion of extubation readiness had a decrease in PedVAE rate from 2.6 to 1.2 events per 1000 ventilator days (absolute rate difference, -1.4; 95% CI, -1.0 to -1.7; P < .001), whereas the other 9 hospitals that did not implement this discussion did not have a decrease.

Conclusions and Relevance

This study found that a multicenter quality improvement intervention targeting PedVAE risk factors was associated with a substantial reduction in the rate of PedVAEs in hospital ICUs. The findings suggest that ICU teams seeking to reduce PedVAEs incorporate daily discussion of extubation readiness during morning rounds.

All Care is Brain Care: Neuro-Focused Quality Improvement in the Neonatal Intensive Care Unit

Neonates requiring intensive care are in a critical period of brain development that coincides with the neonatal intensive care unit (NICU) hospitalization, placing these infants at high risk of brain injury and long-term neurodevelopmental impairment. Care in the NICU has the potential to be both harmful and protective to the developing brain. Neuro-focused quality improvement efforts address 3 main pillars of neuroprotective care: prevention of acquired injury, protection of normal maturation, and promotion of a positive environment. Despite challenges in measurement, many centers have shown success with consistent implementation of best and potentially better practices that may improve markers of brain health and neurodevelopment.

Ventilator-Associated Pneumonia Prevention in Pediatric Patients: Narrative Review

Ventilator-associated pneumonia (VAP), one of the most common healthcare-associated infections in intensive care settings, is associated with significant morbidity and mortality. VAP is diagnosed in >10% of patients on mechanical ventilation, incidence rising with number of ventilator days. In recent decades, the pathophysiology of VAP, VAP risk factors and treatment have been extensively studied. In critically ill pediatric patients, mechanical issues such as insufficient tightness of the ventilator circuit (mainly due to historically based preference of uncuffed tubes) and excessive humidity in the circuit are both significant risk factors of VAP development. Protocol-based approaches to critically ill patients on mechanical ventilation, closed suctioning, upper body position, enteral feeding and selective gastric acid suppression medication have a beneficial effect on VAP incidence. In recent decades, cuffed tubes applied to the whole spectrum of critically ill pediatric patients (except neonates <2700 g of weight), together with cuff-oriented nursing care including proper cuff-pressure (<20 cm H2O) management and the use of specialized tracheal tubes with subglottic suction ports combined with close infraglottic tracheal suctioning, have been implemented. The aim of this review was to summarize the current evidence-based knowledge about the pathophysiology, risk factors, diagnosis, treatment and prevention of VAP in clinically oriented settings.

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

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

Correlation of ICU Nurses' Cognitive Level with Their Attitude and Behavior toward the Prevention of Ventilator-Associated Pneumonia

Objective

To analyze the correlation of ICU nurses' cognitive level with their attitude and behavior toward the prevention of ventilator-associated pneumonia (VAP).

Methods

A total of 90 ICU nurses working in the adult internal medicine ICU, adult surgery ICU, subacute respiratory care ward, etc. from January 2018 to June 2019 were chosen as the subjects to carry out questionnaire survey with the cognition scale, and the correlation analysis on their cognitive level, attitude, and behavior toward the prevention of VAP was conducted.

Results

The linear fitting analysis finding showed that the cognitive level presented a positive correlation with the attitude score and behavior score (R ² = 0.668, 0.734).

Conclusion

Improving ICU nurses' cognitive level, attitude, and behavior toward preventing VAP is conducive to the upgrade of their quality of nursing services. In addition, the ICU nurses' cognitive level is positively correlated with their attitude and behavior.

Values of PCT and STREM-1 combined with clinical pulmonary infection score for the prognostic evaluation of elderly patients with ventilator-associated pneumonia

Objective: To explore the values of PCT and STREM-1 combined with clinical pulmonary infection score (CPIS) for evaluating ventilator-associated pneumonia (VAP) in elderly patients.

Methods: A total of 120 eligible patients were selected as VAP group, and 60 other patients without VAP were selected as control group. According to APACHE II scores, VAP group was divided into low-, medium-, and high-risk groups. The correlations of PCT, STREM-1, and CPIS with APACHE II score were analyzed. The values of PCT and STREM-1 combined with CPIS for evaluating prognosis were analyzed using ROC curves.

Results: In the VAP group, serum PCT and STREM-1 levels and CPIS after mechanical ventilation significantly exceeded those of the control group and before mechanical ventilation (P<0.05). These values were higher in the high-risk group than in medium- and low-risk groups (P<0.05). They were positively correlated with APACHE II score (P<0.001). These values of the death group were significantly higher than those of the survival group 1, 3, 5, and 7 d after treatment (P<0.05). AUC of PCT and STREM-1 combined with CPIS for assessing prognosis was 0.892 (P<0.001).

Conclusions: Serum PCT and STREM-1 levels and CPIS significantly increase in elderly patients with VAP, which rise with aggravation. Their combination has higher values for prognostic evaluation.

The Correlation Between Mechanical Ventilation Duration, Pediatric Sequential Organ Failure Assessment Score, and Blood Lactate Level in Children in Pediatric Intensive Care

OBJECTIVE

This study aimed to investigate whether the ventilation duration for children undergoing invasive mechanical ventilation (IMV) in pediatric intensive care unit (PICU) is correlated with pediatric sequential organ failure (pSOFA) score, white blood cell (WBC) count, blood lactate level, and duration of fever.

METHODS

Retrospectively reviewed that the medical records of patients who received IMV in the PICU of Jingzhou Central Hospital between January 2018 and December 2020. According to the duration of IMV in diagnosis-related groups, these patients were divided into two groups: group A, ventilation duration <96 h, and group B, ventilation duration ≥96 h. Each group's pSOFA scores, WBC counts, blood lactate levels, and durations of fever were compared. Logistic regression analysis was used to analyze the clinical risk factors of ventilation duration ≥96 h, and the receiver operator characteristic (ROC) curve was drawn.

RESULTS

A total of 42 patients were included, including 23 in group A and 19 in group B. The difference in pSOFA score between group A and group B was statistically significant (P < 0.05), while the differences in blood lactate level, duration of fever, and WBC count between the two groups were not statistically significant (P > 0.05). Logistic regression analysis was conducted to analyze the influencing factors of mechanical ventilation duration ≥96 h. An ROC curve was drawn with pSOFA score as a test variable and duration of mechanical ventilation ≥96 h as a state variable, revealing that the area under the curve was 0.76 (SE = 0.075, 95% CI: 0.614-0.906, P = 0.005). The sensitivity and specificity were 68.4 and 73.9%, respectively, and the corresponding pSOFA score was 7.5.

CONCLUSION

When the pSOFA score ≥8, the risk of mechanical ventilation duration ≥96 h increases.

Latin American Consensus on the Management of Sepsis in Children: Sociedad Latinoamericana de Cuidados Intensivos Pediátricos [Latin American Pediatric Intensive Care Society] (SLACIP) Task Force: Executive Summary

OBJECTIVE

The aim of this study was to develop evidence-based recommendations for the diagnosis and treatment of sepsis in children in low- and middle-income countries (LMICs), more specifically in Latin America. Design: A panel was formed consisting of 27 experts with experience in the treatment of pediatric sepsis and two methodologists working in Latin American countries. The experts were organized into 10 nominal groups, each coordinated by a member. Methods: A formal consensus was formed based on the modified Delphi method, combining the opinions of nominal groups of experts with the interpretation of available scientific evidence, in a systematic process of consolidating a body of recommendations. The systematic search was performed by a specialized librarian and included specific algorithms for the Cochrane Specialized Register, PubMed, Lilacs, and Scopus, as well as for OpenGrey databases for grey literature. The GRADEpro GDT guide was used to classify each of the selected articles. Special emphasis was placed on search engines that included original research conducted in LMICs. Studies in English, Spanish, and Portuguese were covered. Through virtual meetings held between February 2020 and February 2021, the entire group of experts reviewed the recommendations and suggestions. Result: At the end of the 12 months of work, the consensus provided 62 recommendations for the diagnosis and treatment of pediatric sepsis in LMICs. Overall, 60 were strong recommendations, although 56 of these had a low level of evidence. Conclusions: These are the first consensus recommendations for the diagnosis and management of pediatric sepsis focused on LMICs, more specifically in Latin American countries. The consensus shows that, in these regions, where the burden of pediatric sepsis is greater than in high-income countries, there is little high-level evidence. Despite the limitations, this consensus is an important step forward for the diagnosis and treatment of pediatric sepsis in Latin America.

Antibiotics for hospital-acquired pneumonia in neonates and children

BACKGROUND

Hospital-acquired pneumonia is one of the most common hospital-acquired infections in children worldwide. Most of our understanding of hospital-acquired pneumonia in children is derived from adult studies. To our knowledge, no systematic review with meta-analysis has assessed the benefits and harms of different antibiotic regimens in neonates and children with hospital-acquired pneumonia.

OBJECTIVES

To assess the beneficial and harmful effects of different antibiotic regimens for hospital-acquired pneumonia in neonates and children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trial registers to February 2021, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised clinical trials comparing one antibiotic regimen with any other antibiotic regimen for hospital-acquired pneumonia in neonates and children.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of the evidence using the GRADE approach. Our primary outcomes were all-cause mortality and serious adverse events; our secondary outcomes were health-related quality of life, pneumonia-related mortality, non-serious adverse events, and treatment failure. Our primary time point of interest was at maximum follow-up.

MAIN RESULTS

We included four randomised clinical trials (84 participants). We assessed all trials as having high risk of bias. We did not conduct any meta-analyses, as the included trials did not compare similar antibiotic regimens. Each of the four trials assessed a different comparison, as follows: cefepime versus ceftazidime; linezolid versus vancomycin; meropenem versus cefotaxime; and ceftobiprole versus cephalosporin. Only one trial reported our primary outcomes of all-cause mortality and serious adverse events. Three trials reported our secondary outcome of treatment failure. Two trials primarily included community-acquired pneumonia and hospitalised children with bacterial infections, hence the children with hospital-acquired pneumonia constituted subgroups of the total sample sizes. Where outcomes were reported, the certainty of the evidence was very low for each of the comparisons. We are unable to draw meaningful conclusions from the numerical results. None of the included trials assessed health-related quality of life, pneumonia-related mortality, or non-serious adverse events.

AUTHORS' CONCLUSIONS

The relative beneficial and harmful effects of different antibiotic regimens remain unclear due to the very low certainty of the available evidence. The current evidence is insufficient to support any antibiotic regimen being superior to another. Randomised clinical trials assessing different antibiotic regimens for hospital-acquired pneumonia in children and neonates are warranted.

Oral mucosal mouthwash with chlorhexidine does not reduce the incidence of ventilator-associated pneumonia in critically ill children: A randomised controlled trial

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most frequently encountered causes of hospital-acquired infection and results in high morbidity among intubated patients. Few trials have investigated the efficacy of oral care with chlorhexidine (CHX) mouthwash for the prevention of VAP in the paediatric population.

OBJECTIVES

The objective of this study was to assess the efficacy of CHX mouthwash in the prevention of VAP and to determine risk factors for VAP in children aged 1 month to 18 years admitted to the paediatric intensive care unit (PICU).

METHODS

This was a prospective, randomised, controlled, double-blind trial performed in the PICU. Patients were randomised into two groups receiving CHX (0.12%) (n = 88) or placebo (0.9% NaCl) (n = 86) and were followed up for VAP development. The main outcome measures were incidence of VAP, duration of hospital stay, duration of PICU stay, duration of ventilation, mortality, and the characteristics of organisms isolated in cases with VAP.

RESULTS

No difference was observed in the incidence of VAP and the type and distribution of organisms in the two groups (p > 0.05). In the CHX and placebo groups, we identified 21 and 22 patients with VAP, respectively. Incidence per 1000 ventilation days was 29.5 events in the CHX group and 35.1 events in the placebo group. Gram-negative bacteria were most common (71.4% in CHX vs. 54.5% in placebo). The use of 0.12% CHX did not influence hospital stay, PICU stay, ventilation, and mortality (p > 0.05). Multivariate analysis identified duration of ventilation as the only independent risk factor for VAP (p = 0.001).

CONCLUSION

The use of 0.12% CHX did not reduce VAP frequency among critically ill children. The only factor that increased VAP frequency was longer duration on ventilation. It appears that low concentration of CHX is not effective for VAP prevention, especially in the presence of multiresistant bacteria. CLINICALTRIALS.

GOV IDENTIFIER

NCT04527276.

Frequency of ventilator circuit changes to prevent ventilator-associated pneumonia in neonates and children-A systematic review and meta-analysis

OBJECTIVE

To assess the effect of different frequencies of ventilator circuit changes in neonates and children through a systematic review and meta-analysis.

INTERVENTIONS

(1) "No routine change of ventilator circuit (unless visibly soiled)" versus "routine change at any fixed interval"; (2) routine change of circuit at "less frequent" versus "more frequent" intervals.

OUTCOMES

Primary outcomes were VAP rate (number of VAP episodes per 1000 ventilator-days) and all-cause mortality before discharge.

METHODS

MEDLINE, CENTRAL, EMBASE, and CINAHL were systematically searched from inception till November 3, 2020. Two authors assessed trial eligibility and risk of bias, and independently extracted data. Data were synthesized using fixed effects model. GRADE was used to assess certainty of evidence (CoE).

RESULTS

We identified six studies enrolling 768 participants evaluating circuit changes at two fixed intervals. Meta-analysis of studies on circuit changes "once in less than 7 days" versus "once weekly" showed no difference in VAP rate (risk ratio: 0.83 [0.38-1.81]; one randomized controlled trial (RCT) and 0.94 [0.49-1.81]; two before-after studies) or mortality before discharge (0.67 [0.34-1.3]; one RCT and 1.01 [0.63-1.64]; two before-after studies). CoE was very low. Less frequent circuit changes reduced health-care costs. No study evaluating "circuit changes only when visibly soiled" versus "circuit changes at a fixed interval" was identified.

CONCLUSION

There is no evidence to suggest that ventilator circuits can be safely left unchanged until visibly soiled in neonates and children. Extending circuit changes interval to "once weekly" may not increase VAP rate (CoE-very low) and reduces healthcare costs.

Sustained reduction of healthcare-associated infections after the introduction of a bundle for prevention of ventilator-associated pneumonia in medical-surgical intensive care units

Background

Infection control interventions can be erroneously interpreted if outcomes are assessed in short periods. Also, statistical methods usually applied to compare outcomes before and after interventions are not appropriate for analyzing time series.

Aims

To analyze the impact of a bundle directed at reducing the incidence of ventilator-associated pneumonia (VAP) and other device-associated infections in two medical-surgical intensive care units (ICU) in Brazil.

Methods

Our study had a quasi-experimental design. Interrupted time series analyses (ITS) was performed assessing monthly rates of overall healthcare-associated infections (HCAI), VAP, laboratory-confirmed central line associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), from January 2007 through June 2019. Moreover, multivariate ITS was adjusted for seasonality in Poisson regression models. An intervention based on a bundle for VAP prevention was introduced in August 2010.

Findings

The intervention was followed by sustained reduction in overall HCAI, VAP and CLABSI in both ICU. Continuous post-intervention trends towards reduction were detected for overall HCAI and VAP.

Conclusion

Interventions aimed at preventing one specific site of infection may have sustained impact on other HCAI, which can be documented using time series analyses.