1. Prevention of Ventilator Associated Pneumonia
Safe Critical Care Project
Vanderbilt-HCA Collaborative

2. 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;

4. 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

5. 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

6. 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

7. 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 *Guidelines for Preventing Health-Care--Associated Pneumonia, 2003 *
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: , 2005

8. 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: , 2005

9. 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:

10. Bad Bugs: Pathogens in VAP (2)
Early–Onset Pneumonia (< 96 hours of intubation or ICU admission)
Community-acquired
Pathogens:
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
Antibiotic-sensitive

11. 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:

12. 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

13. Risk Factors for Nosocomial Pneumonia (cont’d)
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

14. Diagnosing VAP: using flow diagrams as guides
Four diagrams
Algorithm #1: Adolescents and adults
Algorithm #2: Immunocompromised pt.
Algorithm #3: Children 1 to <12 years
Algorithm #4: Infants (<1 year)

16. Algorithm #2: Diagnosing VAP in Immunocompromised Patients

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

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

19. 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

20. Selected references
Centers for Disease Control and Prevention Guidelines for Preventing Healthcare-Associated Pneumonia, 2003, [
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):
Dodek, P and the Canadian Critical Care Trials Group. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med Aug 17;141(4):  
Guidelines for the management of hospital-acquired, ventilator-associated and healthcare-associated pneumonia. Joint statement the American Thoracic Society and the Infectious Diseases Society of America. Am J Respir Crit Care Med 2005, 171:
Kollef M, epidemiology and outcomes of healthcare-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 2005,128:
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):

21. 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