Hospital-Acquired Pneumonia in Nonventilated Patients: The Next Frontier

Hospital-acquired and ventilator-associated pneumonia caused by multidrug-resistant Gram-negative pathogens: Understanding epidemiology, resistance patterns, and implications with COVID-19

The ongoing spread of antimicrobial resistance has complicated the treatment of bacterial hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Gram-negative pathogens, especially those with multidrug-resistant profiles, including Escherichia coli, Klebsiella pneumoniae, Enterobacter spp., Pseudomonas aeruginosa, and Acinetobacter spp., are important culprits in this type of infections. Understanding the determinants of resistance in pathogens causing pneumonia is ultimately stressing, especially in the shadows of the COVID-19 pandemic, when bacterial lung infections are considered a top priority that has become urgent to revise. Globally, the increasing prevalence of these pathogens in respiratory samples represents a significant infection challenge, with major limitations of treatment options and poor clinical outcomes. This review will focus on the epidemiology of HAP and VAP and will present the roles and the antimicrobial resistance patterns of implicated multidrug-resistant (MDR) Gram-negative pathogens like carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Pseudomonas aeruginosa (CRPA), carbapenem-resistant Enterobacterales (CRE), as well as colistin-resistant Gram-negative pathogens and extended-spectrum β-lactamase (ESBL)-producing Enterobacterales. While emerging from the COVID-19 pandemic, perspectives and conclusions are drawn from findings of HAP and VAP caused by MDR Gram-negative bacteria in patients with COVID-19.

Adverse Outcomes of Patients with Non-Ventilator-Associated Hospital-Acquired Pneumonia (nvHAP)-A Single Centre Cohort Study

Non-ventilator associated hospital-acquired pneumonia (nvHAP) is a common nosocomial infection, but little is known about the outcomes of patients with nvHAP and the risk factors for adverse outcomes. In this retrospective study conducted in a Swiss tertiary care centre, adverse outcomes like in-hospital mortality, intensive care unit (ICU) admission, and mechanical ventilation, both all-cause and nvHAP-associated, were investigated. Of 244 patients with nvHAP, 72 (30%) died, 35 (14%) deaths were attributed to nvHAP. While 36 (15%) patients acquired nvHAP on the ICU, another 173 patients were eligible for ICU-transferral, and 76 (43.9%) needed ICU-admission. Of all patients hospitalized on the ICU 58 (51.8%) needed intubation due to nvHAP. Multivariable logistic regression analysis identified lower body mass index (OR per unit increase: 0.90, 95%CI: 0.82-0.98) and lower haemoglobin on admission (OR per unit in g/l increase: 0.98, 95%CI: 0.97-1.00) as patient specific factors independently associated with nvHAP-associated mortality. Given the frequency of nvHAP adverse outcomes, hospitals should evaluate increasing nvHAP prevention efforts, especially for patients at high risk for nvHAP mortality. To what extent pneumonia prevention interventions do lower nvHAP mortality in these patients is still to be evaluated.

Bundle management strategy in reducing hospital-acquired pneumonia in hospitalized patients with mental disorders

Introduction

The incidence of hospital-acquired pneumonia (HAP) is high in the medical setting for mental disorders. To date, effective measurements for preventing HAP in hospitalized mental disorder patients are unavailable.

Methods

This study was conducted at the Large-Scale Mental Health Center of Renmin Hospital of Wuhan University (Wuhan, China) in two phases: baseline phase (January 2017-December 2019) and intervention phase (May 2020-April 2022). In the intervention phase, the HAP bundle management strategy was implemented in the Mental Health Center, and the data on HAP were collected continuously for analysis.

Results

A total of 18,795 and 9,618 patients were included in the baseline and intervention phases, respectively. The age, gender, ward admitted to, type of mental disorder, and Charlson comorbidity index did not differ significantly. After intervention, the rate of HAP occurrence decreased from 0.95 to 0.52% (P < 0.001). Specifically, the HAP rate decreased from 1.70 to 0.95% (P = 0.007) in the closed ward and from 0.63 to 0.35% (P = 0.009) in the open ward. The HAP rate in the subgroups was higher in patients with schizophrenia spectrum disorders (1.66 vs. 0.74%) and organic mental disorders (4.92 vs. 1.41%), and in those ≥65 years old (2.82 vs. 1.11%) but decreased significantly after intervention (all P < 0.05).

Conclusion

The implementation of the HAP bundle management strategy reduced the occurrence of HAP in hospitalized patients with mental disorders.

Oral health status and the etiology and prevention of nonventilator hospital-associated pneumonia

Nonventilator hospital-associated pneumonia has recently emerged as an important preventable hospital-associated infection, and is a leading cause of healthcare-associated infection. Substantial accumulated evidence links poor oral health with an increased risk of pneumonia, which can be caused by bacterial, viral, or fungal pathogens, each with their own distinct mechanisms of transmission and host susceptibility. These infections are frequently polymicrobial, and often include microbes from biofilms in the oral cavity. Evidence documenting the importance of oral care to prevent nonventilator hospital-associated pneumonia is continuing to emerge. Reduction of oral biofilm in these populations will reduce the numbers of potential respiratory pathogens in the oral secretions that can be aspirated, which in turn can reduce the risk for pneumonia. This review summarizes up-to-date information on the role of oral care in the prevention of nonventilator hospital-associated pneumonia.

The incidence and outcomes of healthcare-associated respiratory tract infections in non-ventilated neurocritical care patients: Results of a 10-year cohort study

The incidence of healthcare-associated respiratory tract infections in non-ventilated patients (NVA-HARTI) in neurosurgical intensive care units (ICUs) is unknown. The impact of NVA-HARTI on patient outcomes and differences between NVA-HARTI and ventilator-associated healthcare-associated respiratory tract infections (VA-HARTI) are poorly understood. Our objectives were to report the incidence, hospital length of stay (LOS), ICU LOS, and mortality in NVA-HARTI patients and compare these characteristics to VA-HARTI in neurocritical care patients. This cohort study was conducted in a neurosurgical ICU in Moscow. From 2011 to 2020, all patients with an ICU LOS > 48 h were included. A competing risk model was used for survival and risk analysis. A total of 3,937 ICU admissions were analyzed. NVA-HARTI vs VA-HARTI results were as follows: cumulative incidence 7.2 (95%CI: 6.4-8.0) vs 15.4 (95%CI: 14.2-16.5) per 100 ICU admissions; incidence rate 4.2 ± 2.0 vs 9.5 ± 3.0 per 1000 patient-days in the ICU; median LOS 32 [Q1Q3: 21, 48.5] vs 46 [Q1Q3: 28, 76.5] days; median ICU LOS 15 [Q1Q3: 10, 28.75] vs 26 [Q1Q3: 17, 43] days; mortality 12.3% (95%CI: 7.9-16.8) vs 16.7% (95%CI: 13.6-19.7). The incidence of VA-HARTI decreased over ten years while NVA-HARTI incidence did not change. VA-HARTI was an independent risk factor of death, OR 1.54 (1.11-2.14), while NVA-HARTI was not. Our findings suggest that NVA-HARTI in neurocritical care patients represents a significant healthcare burden with relatively high incidence and associated poor outcomes. Unlike VA-HARTI, the incidence of NVA-HARTI remained constant despite preventive measures. This suggests that extrapolating VA-HARTI research findings to NVA-HARTI should be avoided.

Healthcare-associated infections over an eight year period in a large university hospital in Sicily (Italy, 2011-2018)

Background

Up to 7% of hospitalised patients acquire at least one healthcare-associated infection (HAI). The aim of the present study was to quantify the burden of HAIs in an Italian hospital, identifying involved risk factors.

Methods

Prevalence point study carried out from 2011 to 2018. For each recruited patient, a data entry form was compiled including information on demographics, hospital admission, risk factors, antimicrobial treatment, and infection if present.

Results

A total of 2844 patients were included and 218 (7.03%) reported an infection. HAI prevalence rates showed a significant increase (average annual per cent change (AAPC) +33.9%; p=0.018) from 2011 to 2014 whereas from 2014 to 2018 a gradual decline was observed (AAPC -6.15%; p=0.35). Urinary tract infection was the most common HAI (25.2%) and a total of 166 (76.1%) pathogens were isolated from 218 infections. Enterococcus and Klebsiella species were the most prevalent pathogens, causing 15.1% and 14.5% of HAIs, respectively. A significant higher risk of HAIs was found in patients exposed to central catheter (adjusted odds ratio (adj-OR)=5.40), peripheral catheter (adj-OR=1.89), urinary catheter (adj-OR=1.46), National Healthcare Safety Network surgical intervention (adj-OR=1.48), ultimately fatal disease (adj-OR=2.19) or rapidly fatal disease (adj-OR=2.09) and in patients with longer hospital stay (adj-OR=1.01).

Conclusion

Intervention programmes based on guidelines dissemination and personnel training can contribute to reduce the impact of HAI. Moreover, McCabe score can be a very powerful and efficient predictor of risk for HAI. Finally, an unexpected very high burden of disease due to Enterobacteriaceae and Gram positive cocci that could be related to the frequent use of carbapenems and third generation cephalosporins in this hospital was found.

Factors predicting non-ventilated hospital-acquired pneumonia: systematic review and meta-analysis

BACKGROUND

Hospital-acquired pneumonia (HAP) results in approximately 15-20% of all infections in hospitals, with more than two-thirds being in patients not using mechanical ventilation. The incidence of non-ventilated hospital-acquired pneumonia (NVHAP) is increasing, and it is associated with a longer length of stay, the need for intensive care unit hospitalization and mechanical ventilation use, and higher mortality.

AIM

To identify, quantify, and summarize predictive factors for NVHAP in adult patients admitted to non-intensive care units as determined by previous observational studies.

METHODS

PubMed, Embase, Scopus, and LILACS were systematically searched. Case-control and cohort studies were included, and a meta-analysis was performed for all factors studied more than once. National Institute of Health assessment tools were applied to assess the quality of the studies.

FINDINGS

Thirty-eight articles showing 204 predictive factors were included. A meta-analysis was performed for 58 factors, 32 of which were significantly associated with NVHAP. When the sensitivity analysis was performed without poor-quality studies, 24 factors remained associated with NVHAP.

CONCLUSION

Although there is a lack of good-quality studies to establish predictive factors for NVHAP, the results of this study showed 24 factors associated with the development of this infectious complication. Knowledge of the significant predictive factors for NVHAP will enable the identification of patients most likely to develop it.

Nutritional risk screening score as an independent predictor of nonventilator hospital-acquired pneumonia: a cohort study of 67,280 patients

BACKGROUND

Currently, the association of nutritional risk screening score with the development of nonventilator hospital-acquired pneumonia (NV-HAP) is unknown. This study investigated whether nutritional risk screening score is an independent predictor of NV-HAP.

METHODS

This retrospective cohort study was conducted between September 2017 and June 2020 in a tertiary hospital in China. The tool of Nutritional Risk Screening 2002 (NRS-2002) was used for nutritional risk screening. A total score of ≥3 indicated a patient was "at nutritional risk." Logistic regression was applied to explore the association between the NRS score and NV-HAP.

RESULTS

A total of 67,280 unique patients were included in the study. The incidence of NV-HAP in the cohort for the NRS < 3 and ≥ 3 NRS group was 0.4% (232/62702) and 2.6% (121/4578), respectively. In a multivariable logistic regression model adjusted for all of the covariates, per 1-point increase in the NRS score was associated with a 30% higher risk of NV-HAP (OR = 1.30; 95%CI:1.19-1.43). Similarly, patients with NRS score ≥ 3 had a higher risk of NV-HAP with an odds ratio (OR) of 2.06 (confidence interval (CI): 1.58-2.70) than those with NRS score < 3. Subgroup analyses indicated that the association between the NRS score and the risk of NV-HAP was similar for most strata. Furthermore, the interaction analyses revealed no interactive role in the association between NRS score and NV-HAP.

CONCLUSION

NRS score is an independent predictor of NV-HAP, irrespective of the patient's characteristics. NRS-2002 has the potential as a convenient tool for risk stratification of adult hospitalized patients with different NV-HAP risks.

Association of childhood asthma with postoperative pneumonia

BACKGROUND

Bronchial asthma is the most pervasive chronic disease among children in the United States. Pneumonia, an acute pulmonary disorder, is also quite common, affecting individuals with chronic respiratory conditions. Despite the widespread recognition of bronchial asthma as a common, potentially life-threatening disease, its impact on the risk of serious pulmonary infections such as postoperative pneumonia is under-appreciated. We examined the association of bronchial asthma with postoperative pneumonia in a matched cohort of children who underwent inpatient surgical procedures.

METHOD

We assembled a propensity score-matched retrospective cohort of children (<18 years of age) who underwent inpatient surgery between 2012 and 2015, in hospitals participating in the National Surgical Quality Improvement Program. Our primary outcome was the incidence of postoperative pneumonia. We used Fine-Gray sub-distributional hazard regression to estimate the hazard ratio of postoperative pneumonia, while accounting for the competing risk by mortality.

RESULTS

The unmatched cohort comprised of 93 061 children who met the eligibility criteria, of whom 7.8% (n = 7237) had a preoperative diagnosis of bronchial asthma. The cumulative incidence of pneumonia was 4.5% (95% confidence interval: 2.8%, 8.3%) among children without bronchial asthma and 8.5% (95% confidence interval: 5.8%, 11.8%) among those with bronchial asthma. Throughout the 30-day postoperative period, the risk of pneumonia almost doubled among children with bronchial asthma compared to their nonasthmatic peers (hazard ratio: 1.71; 95% confidence interval: 1.24, 2.35; P = .001).

CONCLUSION

Children with bronchial asthma had a significantly greater risk of postoperative pneumonia. Further studies are needed to understand the mechanisms underlying these associations and determine if perioperative interventions can mitigate this association.

The impact of a bundle to prevent hospital-acquired pneumonia in a cohort of nonventilated patients on enteral nutrition

We conducted a quasi-experimental study to evaluate a bundle to prevent nonventilator hospital-acquired pneumonia (NV-HAP) in patients on enteral tube feeding. After the intervention, there was an increase in bundle compliance from 55.9% to 70.5% (P < .01) and a significant decrease (34%) in overall NV-HAP rates from 5.71 to 3.77 of 1,000 admissions.

Non-ventilator health care-associated pneumonia (NV-HAP)

This guide is intended for IPs, nurses, and others who are involved in infection prevention efforts across the continuum of care. It reviews current literature, suggested prevention strategies, and potential tools and techniques to guide surveillance, detection, and prevention efforts for NV-HAP.

A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system

Objective:

To develop and evaluate a program to presvent hospital-acquired pneumonia (HAP).

Design:

Prospective, observational, surveillance program to identify HAP before and after 7 interventions. An order set automatically triggered in programmatically identified high-risk patients.

Setting:

All 21 hospitals of an integrated healthcare system with 4.4 million members.

Patients:

All hospitalized patients.

Interventions:

Interventions for high-risk patients included mobilization, upright feeding, swallowing evaluation, sedation restrictions, elevated head of bed, oral care and tube care.

Results:

HAP rates decreased between 2012 and 2018: from 5.92 to 1.79 per 1,000 admissions (P = .0031) and from 24.57 to 6.49 per 100,000 members (P = .0014). HAP mortality decreased from 1.05 to 0.34 per 1,000 admissions and from 4.37 to 1.24 per 100,000 members. Concomitant antibiotic utilization demonstrated reductions of broad-spectrum antibiotics. Antibiotic therapy per 100,000 members was measured as follows: carbapenem days (694 to 463; P = .0020), aminoglycoside days (154 to 61; P = .0165), vancomycin days (2,087 to 1,783; P = .002), and quinolone days (2,162 to 1,287; P < .0001). Only cephalosporin use increased, driven by ceftriaxone days (264 to 460; P = .0009). Benzodiazepine use decreased between 2014 to 2016: 10.4% to 8.8% of inpatient days. Mortality for patients with HAP was 18% in 2012% and 19% in 2016 (P = .439).

Conclusion:

HAP rates, mortality, and broad-spectrum antibiotic use were all reduced significantly following these interventions, despite the absence of strong supportive literature for guidance. Most interventions augmented basic nursing care. None had risks of adverse consequences. These results support the need to examine practices to improve care despite limited literature and the need to further study these difficult areas of care.

Incidence and risk factors of non-device-associated pneumonia in an acute-care hospital

OBJECTIVE

To update current estimates of non-device-associated pneumonia (ND pneumonia) rates and their frequency relative to ventilator associated pneumonia (VAP), and identify risk factors for ND pneumonia.

DESIGN

Cohort study.

SETTING

Academic teaching hospital.

PATIENTS

All adult hospitalizations between 2013 and 2017 were included. Pneumonia (device associated and non-device associated) were captured through comprehensive, hospital-wide active surveillance using CDC definitions and methodology.

RESULTS

From 2013 to 2017, there were 163,386 hospitalizations (97,485 unique patients) and 771 pneumonia cases (520 ND pneumonia and 191 VAP). The rate of ND pneumonia remained stable, with 4.15 and 4.54 ND pneumonia cases per 10,000 hospitalization days in 2013 and 2017 respectively (P = .65). In 2017, 74% of pneumonia cases were ND pneumonia. Male sex and increasing age we both associated with increased risk of ND pneumonia. Additionally, patients with chronic bronchitis or emphysema (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.40-3.06), congestive heart failure (HR, 1.48; 95% CI, 1.07-2.05), or paralysis (HR, 1.72; 95% CI, 1.09-2.73) were also at increased risk, as were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18-2.00) or in the ICU (HR, 1.49; 95% CI, 1.06-2.09). We did not detect a change in ND pneumonia risk with use of chlorhexidine mouthwash, total parenteral nutrition, all medications of interest, and prior ventilation.

CONCLUSION

The incidence rate of ND pneumonia did not change from 2013 to 2017, and 3 of 4 nosocomial pneumonia cases were non-device associated. Hospital infection prevention programs should consider expanding the scope of surveillance to include non-ventilated patients. Future research should continue to look for modifiable risk factors and should assess potential prevention strategies.

Sustaining Quality Improvement: Long-Term Reduction of Nonventilator Hospital-Acquired Pneumonia

BACKGROUND

Hospital-acquired pneumonia is now the number one hospital-acquired infection. Hospitals have addressed ventilator-associated pneumonia; however, patients not on a ventilator acquire more pneumonia with significant associated mortality rates.

LOCAL PROBLEM

In our hospital, non-ventilator-associated pneumonia was occurring on all types of units.

METHODS

The Influencer Model was used to reduce nonventilator hospital-acquired pneumonia rates. Statistical process control R and X-bar-charts were monitored monthly.

INTERVENTIONS

After a gap analysis, an interdisciplinary team implemented enhanced oral care before surgery and on the units, changed tube management, and monitored stress ulcer medication.

RESULTS

We achieved a statistically significantly reduction (P = .01) in pneumonia rates that have been sustained over 4 years.

CONCLUSIONS

Sustaining change requires (a) a continued team-based, collaborative approach, (b) ongoing stakeholder and executive leadership engagement, (c) monitoring that easy-to-use protocols and required equipment remain in place, and (d) embedded analytics to monitor results over a prolonged period.

Prevention of hospital-acquired pneumonia

PURPOSE OF REVIEW

Hospital-acquired pneumonia (HAP) is the leading cause of death from hospital-acquired infection. Little work has been done on strategies for prevention of HAP. This review aims to describe potential HAP prevention strategies and the evidence supporting them. Oral care and aspiration precautions may attenuate some risk for HAP. Oral and digestive decontamination with antibiotics may be effective but could increase risk for resistant organisms. Other preventive measures, including isolation practices, remain theoretical or experimental.

RECENT FINDINGS

Hospital-acquired pneumonia occurs because of pharyngeal colonization with pathogenic organisms and subsequent aspiration of these pathogens.

SUMMARY

Most potential HAP prevention strategies remain unproven.

Oral care practices in non-mechanically ventilated intensive care unit patients: An integrative review

AIMS AND OBJECTIVES

To explore current oral care practices in nonmechanically ventilated ICU patients.

BACKGROUND

Oral hygiene is an important aspect of nursing care in hospitalised populations. Oral care is a disease preventive and cost-effective measure for patients, particularly in ICU patients. Numerous studies support the value of oral care practices in mechanically ventilated ICU patients. Due to evidence supporting the benefits of oral care in nonmechanically ventilated patients, it would be beneficial to examine the literature for oral care practices in this population.

METHODOLOGY

Literature searches of the following databases were performed: CINAHL Plus, MEDLINE, PsychInfo, Academic Search Premier, Cochrane Database of Systematic Reviews, and Web of Science. Three peer-reviewed articles were included in the review after inclusion criteria were applied. Findings were appraised, organised conceptually and synthesised using Torraco (2016b) as a guiding framework. Evidence was appraised using the Johns Hopkins Nursing Evidence-based Practice Rating Scale. PRISMA reporting guidelines were followed, when applicable.

RESULTS

Findings support the existing gap in the literature of oral hygiene practices in nonmechanically ventilated ICU patients. Themes included the type of oral care products used, frequencies of oral care, documented oral care practices and personnel that performed the care.

STUDY IMPLICATIONS

This integrative review identified an important gap in the literature for oral care practices in nonmechanically ventilated ICU patient populations. Further research on current oral care practices and development of evidence-based guidelines for this population are recommended.

RELEVANCE TO CLINICAL PRACTICE

Nurses should provide oral care to all hospitalised patients and follow oral care guidelines specific to their population, if available.

Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals

BACKGROUND

A point-prevalence survey that was conducted in the United States in 2011 showed that 4% of hospitalized patients had a health care-associated infection. We repeated the survey in 2015 to assess changes in the prevalence of health care-associated infections during a period of national attention to the prevention of such infections.

METHODS

At Emerging Infections Program sites in 10 states, we recruited up to 25 hospitals in each site area, prioritizing hospitals that had participated in the 2011 survey. Each hospital selected 1 day on which a random sample of patients was identified for assessment. Trained staff reviewed medical records using the 2011 definitions of health care-associated infections. We compared the percentages of patients with health care-associated infections and performed multivariable log-binomial regression modeling to evaluate the association of survey year with the risk of health care-associated infections.

RESULTS

In 2015, a total of 12,299 patients in 199 hospitals were surveyed, as compared with 11,282 patients in 183 hospitals in 2011. Fewer patients had health care-associated infections in 2015 (394 patients [3.2%; 95% confidence interval {CI}, 2.9 to 3.5]) than in 2011 (452 [4.0%; 95% CI, 3.7 to 4.4]) (P<0.001), largely owing to reductions in the prevalence of surgical-site and urinary tract infections. Pneumonia, gastrointestinal infections (most of which were due to Clostridium difficile [now Clostridioides difficile]), and surgical-site infections were the most common health care-associated infections. Patients' risk of having a health care-associated infection was 16% lower in 2015 than in 2011 (risk ratio, 0.84; 95% CI, 0.74 to 0.95; P=0.005), after adjustment for age, presence of devices, days from admission to survey, and status of being in a large hospital.

CONCLUSIONS

The prevalence of health care-associated infections was lower in 2015 than in 2011. To continue to make progress in the prevention of such infections, prevention strategies against C. difficile infection and pneumonia should be augmented. (Funded by the Centers for Disease Control and Prevention.).

Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States

BACKGROUND

Because nonventilator hospital-acquired pneumonia (NV-HAP) is understudied, our purpose was to determine the incidence, overall burden, and level of documented pneumonia preventive interventions of NV-HAP in 24 U.S. hospitals.

METHODS

This retrospective chart review extracted NV-HAP cases as per the 2014 ICD-9-CM codes for pneumonia not present on admission and the 2013 Centers for Disease Control and Prevention case definition. Patient demographic data, outcomes, and documented preventive interventions were also collected.

RESULTS

We found 1,300 NV-HAP patients who acquired NV-HAP (rate, 0.12-2.28 per 1,000 patient days) across the 21 hospitals that completed the data collection. Most NV-HAP infections (70.8%) were acquired outside of intensive care units (ICUs); 18.8% required transfer into the ICU. In the 24 hours prior to diagnosis, most of the patients did not have fundamental hospital care associated with pneumonia prevention.

CONCLUSIONS

This multicenter, nationwide study highlights the significant burden of NV-HAP in the U.S. acute care hospital setting. We found that NV-HAP occurred on every hospital unit, including in younger, healthy patients. This indicates that although some patients are clearly at higher risk, all patients carry some NV-HAP risk. Therapeutic interventions aimed at NV-HAP prevention are frequently not provided for patients in acute care hospitals.

Implementation and Dissemination of a Department of Veterans Affairs Oral Care Initiative to Prevent Hospital-Acquired Pneumonia Among Nonventilated Patients

Implementation and dissemination of an oral care initiative enhanced the safety and well-being of Veterans at the Salem VA Medical Center by reducing the risk of non-ventilator-associated hospital-acquired pneumonia (NV-HAP). The incidence rate of non-ventilator-associated hospital-acquired pneumonia decreased from 105 cases to 8.3 cases per 1000 patient-days (by 92%) in the initial VA pilot, yielding an estimated cost avoidance of $2.84 million and 13 lives saved in 19 months postimplementation. The team was successful in translating this research into a meaningful quality improvement intervention in 8 VA hospitals (in North Carolina, Texas, and Virginia) that has promoted effective and consistent delivery of oral care across hospital service lines and systems, improved the health of Veterans, and driven down health care costs associated with this largely preventable illness. The steps needed for successful replication and dissemination of this nurse-led, evidence-based practice are summarized in this article.

Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review

Background

Pneumonia is one of the leading hospital-acquired infections worldwide and has an important impact. Although preventive measures for ventilator-associated pneumonia (VAP) are well known, less is known about appropriate measures for prevention of hospital-acquired pneumonia (HAP).

Aim

The purpose of this narrative review is to provide an overview of the current standards for preventing HAP in non-ventilated adult patients.

Methods

A search of the literature up to May 2015 was conducted using Medline for guidelines published by national professional societies or professional medical associations. In addition, a comprehensive search for the following preventive measures was performed: hand hygiene, oral care, bed position, mobilization, diagnosis and treatment of dysphagia, aspiration prevention, viral infections and stress bleeding prophylaxis.

Findings

Regarding international guidelines, several measures were recommended for VAP, whilst no specific recommendations for HAP prevention in non-ventilated patients are available. There is reasonable evidence available that oral care is associated with a reduction in HAP. Early mobilization interventions, swift diagnosis and treatment of dysphagia, and multimodal programmes for the prevention of nosocomial influenza cross-infection, have a positive impact on HAP reduction. The impact of bed position and stress bleeding prophylaxis remains uncertain. Systematic antibiotic prophylaxis for HAP prevention should be avoided.

Conclusion

Scant literature and little guidance is available for the prevention of HAP among non-ventilated adult patients. In addition, the criteria used for the diagnosis of HAP and the populations targeted in the studies selected are heterogeneous. Oral care was the most studied measure and was commonly associated with a decrease in HAP rate, although a broad range of interventions are proposed. No robust evidence is available for other measures. Further high-quality studies are required to evaluate the impact of specific measures on HAP prevention in non-ventilated adult patients.