Prevention of Ventilator

Associated Pneumonia
Safe Critical Care Project
Vanderbilt-HCA Collaborative

Ventilator Associated Pneumonia (VAP) Key Points VAP is the 2nd most common nosocomial infection =
15% of all hospital acquired infections
Incidence = 9% to 70% of patients on ventilators
Increased ICU stay by several days
Increased avg. hospital stay 1 to 3 weeks
Mortality = 13% to 55%
Added costs of $40,000 - $50,000 per stay
Centers for Disease Control and Prevention, 2003.
Rumbak, M. J. (2000). Strategies for prevention and treatment. Journal of Respiratory Disease, 21
(5), p. 321;

Challenge and Controversy

There is no doubt that the diagnosis and
management of VAP remains one of the
most controversial and challenging topics
in management of critically ill patients.

Chan C, Chest 2005;127:425

Changing Views of VAP

No longer just an unfortunate occurrence
Viewed as medical error
Institute of Medicine
Leapfrog Group

JCAHO hospitals required to show VAP

prevention/reduction measures

Diagnosing VAP
VAP is a Nosocomial Pneumonia = Hospital
acquired
Diagnosis is imprecise and usually based on
a Combination of:
Clinical factors - fever or hypothermia; change in
secretions; cough; apnea/bradycardia; tachypnea

Microbiological factors - positive cultures of

blood/sputum/tracheal aspirate/pleural fluids

CXR factors - new or changing infiltrates

DiagnosingVAP
Diagnosis of VAP can be a confusing and complicated process.
In order to clarify the process and help clinicians, the Centers
for Disease Control and Prevention (CDC) published
guidelines for diagnosing VAP in 2003
*Guidelines for Preventing Health-Care--Associated Pneumonia, 2003
* http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

These guidelines were revised and updated in a joint statement

published by the American Thoracic Society and the Infectious
Diseases Society of America
* Am J Respir Crit Care Med 171:388-416, 2005

Diagnosing VAP

For this project, we used the revised guidelines

to developed tools to help clinicians with
making the diagnosis.

Am J Respir Crit Care Med 171:388-416, 2005

Bad Bugs: Pathogens in VAP (1)

Pathogens that cause VAP differ depending on
whether the condition occurs early (less than
96 hours after intubation or admission to ICU)
or late (greater than 96 hours after intubation
or admission to ICU)
Kollef M, Chest 2005;128:3854-62

Bad Bugs: Pathogens in VAP (2)

EarlyOnset Pneumonia (< 96 hours of
intubation or ICU admission)
Community-acquired
Pathogens:
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus

Antibiotic-sensitive

Bad Bugs: Pathogens in VAP (3)

Late-Onset Pneumonia (> 96 hours of
intubation or ICU admission)
Hospital-acquired
Pathogens:

Pseudomonas aeruginosa
Methicillin resistant Staphylococcus aureus (MRSA)
Acinetobacter
Enterobacter

Antibiotic-resistant
Kollef M, Chest 2005;128:3854-62

Risk Factors for

Nosocomial Pneumonia
Major risk factor = mechanical intubation
Factors that enhance colonization of the oropharynx &/or
stomach:
Administration of antibiotics
Admission to ICU
Underlying chronic lung disease

Conditions favoring aspiration into the respiratory tract or

reflux from GI tract:

Supine position *GERD

NGT placement *Coma/delirium
Intubation and self-extubation
Immobilization
Surgery of head/neck/thorax/upper abdomen

Risk Factors for

Nosocomial Pneumonia (contd)
Conditions requiring prolonged use of mechanical
ventilatory support with potential exposure to
contaminated respiratory devices &/or contact with
contaminated hands
Host Factors:

Extremes of age
Malnutrition
Immunocompromised
Underlying condition/disease process
Cook D et al, Ann Intern Med 1998;129:433-40

Diagnosing VAP:
using flow diagrams as guides
Four diagrams
Algorithm #1:
Algorithm #2:
Algorithm #3:
Algorithm #4:

Adolescents and adults

Immunocompromised pt.
Children 1 to <12 years
Infants (<1 year)

Algorithm #2: Diagnosing VAP in Immunocompromised Patients

Algorithm #3: Diagnosing VAP in Children (Age >1 and <13 years)

Algorithm #4: Diagnosing VAP in Infants (Age <1 year old)

VAP Antibiotic Selection

(introductory comments)
Considerations in making selection

Setting (community, NH, hospital)

Suspected organism (GNRs, GPCs)
Host factors (immunosuppression)
Local susceptibility patterns

Initial empiric and broad; subsequent narrowing

Concept is to not miss the organism with initial
coverage and then de-escalate when able

Selected references
Centers for Disease Control and Prevention Guidelines for Preventing Healthcare-Associated
Pneumonia, 2003, [http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm]
Cook D et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill
patients. Ann Intern Med 1998 Sep 15;129(6):433-40.
Dodek, P and the Canadian Critical Care Trials Group. Evidence-based clinical practice guideline
for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004 Aug
17;141(4):305-13.
Guidelines for the management of hospital-acquired, ventilator-associated and healthcareassociated pneumonia. Joint statement the American Thoracic Society and the Infectious
Diseases Society of America. Am J Respir Crit Care Med 2005, 171:388-416.
Kollef M, epidemiology and outcomes of healthcare-associated pneumonia: results from a large
US database of culture-positive pneumonia. Chest 2005,128:3854-62.
Langley JM, Bradley JS. Defining pneumonia in critically ill infants and children. Pediatr Crit
Care Med 2005, 6[supplement]:S9-S13.
Rumbak, M. J. Strategies for prevention and treatment. Journal of Respiratory Diseases, 2000,
21(5):321-327.

Ventilator associated Pneumonia

Next webcast will focus on Ventilator Bundle:
Interventions to prevent or reduce VAP
Check lists to help the patient care team
Discussion of antibiotic choices

Webcast