Post on 03-Dec-2021
Multimodal approaches for ventilator-associated pneumonia
Maria Adriana Cataldo
National Institute for Infectious Diseases “L. Spallanzani”, Rome
30 November - 2 December 2011, Rome, Italy
HD# 5
- severe CODP exacerbation
- presence of risk factors for P. aeruginosa
started pip/tazo + gentamycin
HD#7
- BAL grew P. aeruginosa susceptible to quinolones and anti-
pseudomonal beta-lactams
- Improvement of hypoxia
AT was not changed
HCWs decided to evaluate possibility of weaning the day after
Patient to nurse ratio: 3 to 1
New nurses with little experience
HH measures compliance not recently checked
No recent educational meeting on VAP prevention
No constant semirecumbent position
No regular oral care with antiseptic
No selective digestive decontamination
HD#9MV day 4Severe hypoxiaNew chest X rayDiagnosis of VAP
VAP is due to several factors:
tubes
aspiration of the nasal and oropharyngeal secretions
underlying morbidity and impairment of host defenses
active surveillance for VAP
adhere to hand-hygiene guidelines
use noninvasive ventilation whenever possible
minimize the duration of ventilation
daily assessments of readiness to wean and use of weaning
protocols
educate HCWs about VAP
semirecumbent position (30-45 elevation of the head of the bed)
avoid gastric overdistention
avoid unplanned extubation and reintubation
perform subglottic secretion drainage
orotracheal instead of nasotracheal intubation
regular oral care with an antiseptic solution
use sterile water to rinse reusable respiratory equipment
remove condensate from ventilatory circuits.
keep the ventilatory circuit closed during condensate removal
change the ventilatory circuit only when visibly soiled or
malfunctioning.
store and disinfect respiratory therapy equipment properly
No clear recommendation in GL
Use still controversial
non-absorbable oral antibiotics (polymyxin, tobramycin and
amphotericin B) topically to the oropharynge and stomach
intravenous administration of cefotaxime
Several meta-analyses: efficacy in decreasing the VAP rate and
mortality
Cochrane review: combination of topical and systemic prophylactic
antibiotics reduces respiratory tract infections and overall mortality
Use of topical prophylaxis alone reduced respiratory infections but
not mortality
- Kollef MH et al, Chest 1994;- Hurley JC, Antimicrob Agents Chemother 1995- D’Amico R et al, BMJ 1998- Nathens AB et al, Arch Surg 1999- Van Nieuwenhoven CA et al, JAMA 2001- Liberati A et al, Cochrane Database Syst Rev 2004
Its use not generalised worldwide: concern antibiotic development
Most experts recommendations still cautious
SHEA/IDSA GL: unresolved issue
European experts panel: routine use should be discouraged
UK GL: should be considered where it is anticipated MV≥ 48h
Meta-analysis: SDD led to trends towards colonization with Gram-
positive and pneumonia due to resistant Gram-negative
Cochrane review: no evidence of generalized emergence of
resistance, only isolated reports.
UK GL: absence of evidence that use of SDD results in emergence
and generalized spread of resistance
- Kollef MH et al, Chest 1994- Liberati A et al. Cochrane Database Syst Rev 2004
Open-label, clustered group-randomised, crossover study 13 ICUs Netherlands -SOD (topical tobramycin, colistin, and amphotericin B in the oropharynx)-SDD (SOD antibiotics in the oropharynx and stomach plus 4 days’intravenous cefotaxime)- standard careOutcomes: rate of acquired bacteraemia and respiratory tract colonization by AR bacteriaSDD vs standard care: lower rate of bacteraemia and respiratory tract colonization SOD vs standard care: lower rate of respiratory tract colonisation
Kaplan-Meier analysis of time to event of acquisition of cefotaxime-resistant Enterobacteriaceae
IV cefotaxime vs standard care and SOD: lower rate of cefotaxime-resistant Enterobacteriaceae in the respiratory tract
Extended use of SDD and SOD justified in settings with low rates of
antibiotic resistance.
The long-term effects on development of resistance should be
monitored
No available evidence on the best drug and doses
UK GL:
- include topical and parenteral agents anti-Gram-negative,
- drug choice depend on local antimicrobial susceptibility profiles
Duration of administration: SDD throughout the ICU stay, with the
systemic element for 3–4 days only
Some studies: protective effect on early VAP
Other showed higher risk of VAP
Meta-analysis 8 RCTs: aerosolised aa decreased VAP rate, no effect on
mortality.
Double-blind RCT: no lower incidence of VAP in the treatment group
- Sirvert JM et al, Am J Respir Crit Care Med 1997- Rello J et al, Am J Respir Crit Care Med 1999- Trouillet JL et al, Am J Respir Crit Care Med 1998- Ewig S et al Am J Respir Crit Care Med 1999- Claridge JA et al, Surg Infect (Larchmt) 2007
Canadian guidelines: no recommendation
SHEA/IDSA: not recommended routinely use
UK GL: systemic antibiotic prophylaxis only as part of SDD
Recently the awareness of the need for a multifaceted
approach has been increasing
Institute for Healthcare Improvement 5-component bundle:
◦ Elevation of the head of the bed
◦ Daily sedation vacations and assessment of readiness to extubate
◦ Peptic ulcer disease prophylaxis
◦ Deep venous thrombosis prophylaxis
◦ Daily oral care with chlorexidine
Several reports of success using this bundle
Certain recommended interventions not strongly supported by
evidence
Not all directly target VAP
New care bundle based on interventions discussed in European GL
Multicriteria decision analysis was used with a process of “weighting
and scoring”
Enforcement: daily infection control rounds with compliance assessment
pre-VAP bundle: 5.2 VAP/1,000 ventilation days
VAP bundle implementation: 2.4/1,000 days (NS)
VAP bundle enforcement: 1.2/1,000 days (NS)
including all trauma patients : significant decrease of VAP rate in
the enforcement period, but not in the implementation period
Necessity for strict compliance
Most recently published studies: emphasis on compliance
assessment and education
Educational program to improve prevention, reminders and compliance
assessment
8 preventive measures
1) HH with alcohol-based hand sanitizer
2) Gloves and gowns
3) Semirecumbent position
4) Endotracheal cuff pressure>20 cm H2O
5) Orogastric tube
6) Avoiding gastric overdistension
7) Mouth decontamination with chlorexidine at least 4 times/day
8) Avoiding nonessential tracheal suction
Other measures included
changing heat and moisture exchangers every 7 days or when
visibly soiled
keeping the same ventilator circuit in a given patient unless visibly
soiled or malfunctioning.
no continuous subglottic secretion aspiration or closed endotracheal
suctioning system
no SDD routinely
no stress ulcer prophylaxis routinely
standardized weaning protocol
Comparison VAP rates
Baseline period (45 months) before introduction multimodal strategy
Intervention period (30 months)
Significant improvement of compliance:
hand hygiene and glove-gown use: 68% and 80%, and stable over
time
keeping patients in the semirecumbent position: 5%–58%
maintaining an endotracheal tube cuff pressure: 40%–89%
using an orogastric tube: 52%–96%
avoiding gastric overdistension: 20%–68%
oral decontamination: 47%–90%
no use of nonessential tracheal suction: 41%–92%
Bouadma et al, Crit Care Med 2010
Before the intervention, VAP incidence density showed a nonsignificant increase over time (p.11). The intervention was associated with a significant decrease in VAP incidence rates (p.001).
Cox proportional hazard model:
Intervention decreased the VAP
incidence rate by 43% (HR, 0.57)
Multifaceted intervention to increase adherence to 5 preventive
measures:
1. semirecumbent positioning
2. stress ulcer prophylaxis
3. deep venous thrombosis prophylaxis
4. adjustment of sedation
5. daily assessment of readiness to extubate
Baseline data vs post-implementation (30 months)
Compliance with the 5 measures increased during the study period
VAP rate significantly decreased
- 5.5 cases/1,000 ventilator-days at baseline
- 0 cases at 18 months and at 30 months after implementation (P < .001)
Overall 71% reduction in VAP rate
Effectiveness of multimodal strategies for the prevention of VAP
Some shortcomings:
- methodological flaws in design, reporting and results of the
studies
- the various VAP prevention bundles proposed different
combination and number of interventions
- no consensus on the best combination
- concern on applicability in daily practice
Importance of the 100% compliance with the prevention measures
Non-completion of a single intervention equates to failure of the
whole bundle
Best implementation tailored to the local situation
Simple measures that can be monitored
Formulated into a simple document
Unmodifiable risk factorsDiabetesCODPOld age
Risk factors which would had been modified in the remote pastExposure to several antibioticsSeveral hospitalizations
Risk factors which would had been modified in the recent pastExposure to antibiotics High likelihood of aspirationHigh likelihood of colonization of the aerodigestive tract with AR Gram-negative bacteria
De-escalation of AT after 48 h
Constant semirecumbent position
Daily assessment of readiness to extubate
Regular oral care
Adherence to hand-hygiene measures and contact precaution
Active screening for colonization by MDR-bacteria
Nurses workload
Little experience
Decreased attention to HCWs education
No clear knowledge of the prevention measures
Written policy for VAP prevention
Regular education meetings
Regular assessment of compliance
Feedback to HCWs
Inconsistent evaluation of the possibility of extubation
Applicability of semirecumbent position in daily practice largely criticised
Frequent low compliance with hand-hygiene measures among HCWs
Low adherence to antimicrobial stewardship principles worldwide
Low full compliance with VAP bundles
Compliance with individual elements: no impact on VAP rate
Several surveys: lack of knowledge about VAP prevention
Simple distribution of guidelines is insufficient to change physician behaviour
Does this happen in real life?Does this happen in real life?
Systematic review of interventions to reduce HAIsSystematic review of interventions to reduce HAIs
With current evidenceWith current evidence--based strategies may be preventable:based strategies may be preventable:
-- 6565--70% of cases of catheter70% of cases of catheter--associated BSI and UTIassociated BSI and UTI
-- 55% of cases of VAP and SSI 55% of cases of VAP and SSI
Highest number of preventable deaths: CABSI followed by VAPHighest number of preventable deaths: CABSI followed by VAP