Ventilator-associated pneumonia in paediatric intensive care: a literature review

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.

Ventilator Associated Pneumonia in Children

Ventilator associated pneumonia (VAP) is a common complication in mechanically ventilated children and adults. There remains much controversy in the literature over the definition, treatment and prevention of VAP. The incidence of VAP is variable, depending on the definition used and can effect up to 12% of ventilated children. For the prevention and reduction of the incidence of VAP, ventilation care bundles are suggested, which include vigorous hand hygiene, head elevation and use of non-invasive ventilation strategies. Diagnosis is mainly based on the clinical presentation with a lung infection occurring after 48hours of mechanical ventilation requiring a change in ventilator settings (mainly increased oxygen requirement, a positive culture of a specimen taken preferentially using a sterile sampling technique either using a bronchoscope or a blind lavage of the airways). A new infiltrate on a chest X ray supports the diagnosis of VAP. For the treatment of VAP, initial broad-spectrum antibiotics should be used followed by a specific antibiotic therapy with a narrow target once the bacterium is confirmed.

Bacteremia and pneumonia in a tertiary PICU: an 11-year study

OBJECTIVES

To describe trends in aetiology and resistance patterns and patient outcomes of bacteraemia and pneumonia in a PICU over an 11-year period. We also describe interventions aimed at reducing multi-resistant infections and other serious bacterial infections in the PICU.

DESIGN AND SETTING

This cohort study involved data collected between January 2002 and December 2012 in the PICU of the Royal Children's Hospital in Melbourne, Australia. We documented all bacterial and fungal pathogens isolated from culture of blood or bronchial alveolar lavage fluid. Trends in aetiology and antibiotic resistance patterns were evaluated, as well as the case fatality rates of population-subgroups.

PATIENTS, MEASUREMENT AND MAIN RESULTS

Overall, 881 patients (8.9%) had 1,480 serious bacterial or fungal infections and 1.2% of the PICU population suffered a multidrug-resistant infection. Twenty-six percent of 597 total deaths in the PICU during that time period were associated with a serious bacterial infection of the blood or lungs. Children in PICU with a serious infection in blood or lungs had a case fatality rate of 17.5% (95% CI, 15.0-20.2), compared with children overall in the PICU with a case fatality rate of 6.0% (95% CI, 5.5-6.5). The case fatality rate among children with multidrug-resistant sepsis was 25.6% (95% CI, 18.1-34.4) and among children with a persistent or recurrent infection in blood or lungs was 43.1% (95% CI, 30.8-56.0). Cases of multidrug-resistant bacteremia and bronchial alveolar lavage-proven pneumonia increased from 2002 to 2010 and significantly decreased from 2011, coinciding with improvements in antibiotic stewardship and infection control.

CONCLUSIONS

Multiresistant bacterial sepsis and persistent or recurrent sepsis are major threats in pediatric intensive care and are associated with disproportionally high death rates. Our study describes a model for monitoring these serious infections and the effects of infection control interventions in the PICU.

Preventing ventilator-associated pneumonia in children: an evidence-based protocol

Ventilator-associated pneumonia, the second most common hospital-acquired infection in pediatric intensive care units, is linked to increased morbidity, mortality, and lengths of stay in the hospital and intensive care unit, adding tremendously to health care costs. Prevention is the most appropriate intervention, but little research has been done in children to identify necessary skills and strategies. Critical care nurses play an important role in identification of risk factors and prevention of ventilator-associated pneumonia. A care bundle based on factors, including evidence regarding the pathophysiology and etiology of pneumonia, mechanical ventilation, duration of ventilation, and age of the child, can offer prompts and consistent prevention strategies for providers caring for children in the pediatric intensive care unit. Following the recommendations of the Centers for Disease Control and Prevention and adapting an adult model also can support this endeavor. Ultimately, the bedside nurse directs care, using best evidence to prevent this important health care problem.

Oral care practices of intensive care nurses: a descriptive study

The aim of this study was to investigate intensive care unit (ICU) nurses' views and practices on oral care and to define the factors related to oral care measures. A study was carried out in eight ICUs of a teaching hospital in 2008. One hundred one nurses constituted the study sample. The data were collected using 'Oral Care Practices Survey' which included demographic characteristics (5 items) and current oral care practices (13 items). Oral care was given the highest priority by nearly 60% of the nurses. The most commonly used solution was sodium bicarbonate (79.2%), and the most frequently used equipment was foam swab (82.2%). Oral care was carried out less than every 4 h per day by 44.5% of the nurses. The oral care products and solutions were reported to be different in almost every unit. The relationship between the use of toothpaste and the place of employment was statistically significant (x(2) = 24.566, d.f. = 6, P = 0.000). There was a statistical significance between the clinics and frequency of oral care (x(2) = 81.486, d.f. = 42, P = 0.000). This study suggests that there is a wide variety of type and frequency of oral care measures among ICU nurses. Optimal oral care supported by evidence is an effective prevention method for eliminating oral complications.

The oral health of critically ill children: an observational cohort study

AIMS AND OBJECTIVES

This study will describe the oral health status of critically ill children over time spent in the paediatric intensive care unit, examine influences on the development of poor oral health and explore the relationship between dysfunctional oral health and healthcare-associated infections.

BACKGROUND

The treatment modalities used to support children experiencing critical illness and the progression of critical illness may result in dysfunction in the oral cavity. In adults, oral health has been shown to worsen during critical illness as well as influence systemic health.

DESIGN

A prospective observational cohort design was used.

METHOD

The study was undertaken at a single tertiary-referral Paediatric Intensive Care Unit. Oral health status was measured using the Oral Assessment Scale and culturing oropharyngeal flora. Information was also collected surrounding the use of supportive therapies, clinical characteristics of the children and the occurrence of healthcare-associated infections.

RESULTS

Of the 46 participants, 63% (n = 32) had oral dysfunction and 41% (n = 19) demonstrated pathogenic oropharyngeal colonisation during their critical illness. The potential systemic pathogens isolated from the oropharynx and included Candida sp., Staphylococcus aureus, Haemophilus influenzae, Enterococcus sp. and Pseudomonas aeruginosa. The severity of critical illness had a significant positive relationship (p < 0·05) with pathogenic and absent colonisation of the oropharynx. Sixty-three percent of healthcare-associated infections involved the preceding or simultaneous colonisation of the oropharynx by the causative pathogen.

CONCLUSIONS

This study suggests paediatric oral health to be frequently dysfunctional and the oropharynx to repeatedly harbour potential systemic pathogens during childhood critical illness.

RELEVANCE TO CLINICAL PRACTICE

Given the frequency of poor oral health during childhood critical illness in this study and the subsequent potential systemic consequences, evidence based oral hygiene practices should be developed and validated to guide clinicians when nursing critically ill children.

Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation after endotracheal intubation. The role of chlorhexidine and tooth-brushing has been considered as a clinical intervention to reduce infection rates, however, evidence to inform this needs appraising.

AIM

This paper presents a critical review on the effect of chlorhexidine gluconate (CHX) and tooth-brushing in decreasing rates of VAP in mechanically ventilated adult patients cared for in intensive care settings.

METHODS

A literature search was conducted using a number of bibliographic databases (n = 6). A number of parameters were used to exclude irrelevant papers. A total n = 17 papers were located and accessed, which were directly related to the field. Eight studies that met the criteria and addressed the study aims were reviewed.

FINDINGS

CHX was successful in reducing the rate of VAP and using a combination of CHX and colistine resulted in better oropharyngeal decontamination which reduced and delayed VAP. Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive care and had the potential to reduce nosocomial infections. Results of studies investigating the use of tooth-brushing in reducing VAP incidence proved inconsistent, although all recommend tooth-brushing as important in maintaining good oral hygiene.

CONCLUSIONS

The use of chlorhexidine has been proven to be of some value in reducing VAP, although may be more effective when used with a solution which targets gram-negative bacteria. Tooth-brushing is recommended in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study design and inconsistency in results suggest that further research is required into the effects of tooth-brushing.

Ventilator-associated pneumonia: the importance of oral care in intubated adults

Ventilator-associated pneumonia (VAP) occurs within 24 hours of intubation and mechanical ventilation. Health care costs related to increased patient mortality, extended length of stay, and patient well-being make treatment of VAP a priority in all health care settings. The Institute for Healthcare Improvements has developed the Ventilator Bundle as a group of interventions linked to ventilator care with demonstrated outcome improvements; removal of subglottic secretions is one of these recommendations. Dental plaque and bacterial colonization of pathogens is directly related to microaspiration of bacteria into the lungs. A moist environment in the mouth maintains normal oropharyngeal bacteria, preventing overgrowth of pathogenic bacteria. Frequent oral care to include twice-a-day brushing of the teeth found a 69% reduction in respiratory tract infections.