Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events

INTRODUCTION

Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP.

AREAS COVERED

This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles.

EXPERT OPINION

Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.

Efficacy of Intermittent and Continuous Subglottic Secretion Drainage in Preventing the Risk of Ventilator-Associated Pneumonia: A Meta-Analysis of Randomized Control Trials

Ventilator-associated pneumonia (VAP) is hospital-acquired pneumonia that develops 48 h or longer following mechanical ventilation. However, cuff pressure fluctuates significantly due to patient or tube movement, which might result in microaspiration. Subglottic secretion drainage (SSD) has been suggested as a method for VAP prevention bundles. This systematic review and meta-analysis aims to investigate the efficacy and safety of subglottic SSD in preventing VAP. The secondary outcomes of this study are to investigate the intensive care unit (ICU) stay length and mortality rate regarding VAP. This study followed the Preferred Reporting Item for Systematic Review and Meta-Analysis guidelines. A thorough search of PubMed, Embase, and the Web of Science was conducted between June and August 2022. The study analysis used the Mantel-Haenszel method, and the quality of the included study was assessed using the Cochrane Risk of Bias 2. Eighteen randomized controlled trials with a total of 2537 intubated patients were included. It was found that SSD was associated with a lower risk of VAP (RR 1.44; 95% CI; 1.20-1.73; p < 0.0001). The subgroup analysis (utilizing intermittent and continuous methods) found no statistically significant difference between the two groups (p = 0.28). The secondary endpoints showed that there was no significant difference in mortality (RR 1.02; 95% CI; 0.87-1.20; p = 0.83), but there were substantial differences in ICU stays (mean difference, 3.42 days; 95% CI; 2.07-4.76; p < 0.00001) in favor of the SSD group. This was based on a very low certainty of evidence due to concerns linked to the risk of bias and inconsistency. The use of SSD was associated with a reduction in VAP incidence and ICU stay length, but there was no significant difference in the mortality rate.

Intra-tracheal multiplexed sensing of contact pressure and perfusion

Incorrect endotracheal tube (ETT) cuff inflation pressure causes significant problems for intubated patients. The technical development and first in vivo use of a smart ETT for measurements at the cuff-trachea interface during mechanical ventilation are described. The intra-tracheal multiplexed sensing (iTraXS) ETT contains integrated optical fibre sensors to measure contact pressure and blood perfusion. The device is tested during mechanical ventilation in a porcine model (N=6). For contact pressure, signals were obtained in all 30 measurements. For perfusion, data could be obtained in all 33 measurements. In the 3 cases where the cuff was inflated to an artificially high-level, blood occlusion is observed.

Efficacy of Venner-PneuX endotracheal tube system for prevention of ventilator-associated pneumonia in intensive care units: A protocol for systematic review and meta-analysis

BACKGROUND

The pathogenic mechanism and prevention of ventilator-associated pneumonia (VAP) are substantially improved over the past several decades, but VAP remains frequently seen among the critical cases. The Venner-PneuX endotracheal tube system (VPXETS) has been proved to perform better than standard endotracheal tubes (SET) in the prevention of VAP in some studies. Therefore, this systematic review is aimed at evaluating the effectiveness of VPXETS in order to prevent VAP.

METHODS

Electronic databases, including PubMed, WANFANG, CENTRAL, CNKI, EMBASE, and CINAHL, are used to search relevant randomized controlled trials for evaluating the therapeutic effect of VPXETS on preventing VAP from January 2011 to December 2020. To be specific, related studies are selected, data are extracted, risk of bias is assessed, and meta-analysis is conducted in succession.

RESULTS

The present review aims to assess the therapeutic effect of VPXETS on preventing VAP in intensive care units (ICUs). Our outcome measures include the incidence and side reaction of VAP.

CONCLUSIONS

The present review assesses related studies regarding the therapeutic effect of VPXETS on preventing VAP at ICUs.

DISSEMINATION AND ETHICS

Our findings in this work are to be disseminated by means of peer-reviewed publication. No ethical approval is required in our review since it uses the published data. Moreover, anonymity is guaranteed during the data analysis process.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/6BERJ.

Effect of Perioperative Subglottic Secretion Drainage on Ventilator-Associated Pneumonia After Cardiac Surgery: A Retrospective, Before-and-After Study

OBJECTIVES

Although postoperative subglottic secretion drainage prevents ventilator-associated pneumonia (VAP) after cardiac surgery, its role during the perioperative period is unclear. For the present study, the effect of subglottic secretion drainage during and after cardiac surgery on postoperative VAP was investigated.

DESIGN

Retrospective, single-center, before-and-after study.

SETTING

Perioperative care of cardiac surgical patients in a tertiary university hospital.

PARTICIPANTS

Adult patients who underwent cardiac surgery from January 2013-December 2018.

INTERVENTIONS

Conventional and subglottic suctioning endotracheal tubes were used in the control and intervention groups before and after a change in institutional policy, respectively. In the intervention group, subglottic secretion drainage was performed continuously during surgery and intermittently after surgery.

MEASUREMENTS AND MAIN RESULTS

The risk of postoperative VAP, identified by the National Healthcare Safety Network surveillance definition algorithm, was compared by weighted logistic regression. Logistic regression analyses, with propensity score matching and inverse probability weighting, also were performed. A total of 2,576 patients were analyzed (control [n = 2108]; intervention [n = 468]). Postoperative VAP occurred less frequently in the intervention group (1/468 [0.2%]) compared with the control group (30/2,108 [1.4%]). In the multivariate weighted logistic regression analysis, the risk of VAP after cardiac surgery was significantly lower in the intervention group than in the control group (odds ratio 0.29; 95% confidence interval 0.14-0.58). Similar results were obtained in multivariate analyses after propensity score matching (odds ratio 0.04; 95% confidence interval 0.01-0.14) and inverse probability weighting (odds ratio 0.16; 95% confidence interval 0.05-0.42).

CONCLUSIONS

Routine perioperative subglottic secretion drainage using subglottic suctioning endotracheal tubes in patients undergoing cardiac surgery was associated with a reduction in the risk of VAP after surgery.

Pathogenesis-Targeted Preventive Strategies for Multidrug Resistant Ventilator-Associated Pneumonia: A Narrative Review

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU), accounting for relevant morbidity and mortality among critically ill patients, especially when caused by multidrug resistant (MDR) organisms. The rising problem of MDR etiologies, which has led to a reduction in treatment options, have increased clinician’s attention to the employment of effective prevention strategies. In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing MDR-VAP. Oral hygiene with Chlorhexidine (CHX), CHX body washing, selective oral decontamination (SOD) and/or digestive decontamination (SDD), multiple decontamination regimens, probiotics, subglottic secretions drainage (SSD), special cuff material and shape, silver-coated endotracheal tubes (ETTs), universal use of gloves and contact isolation, alcohol-based hand gel, vaporized hydrogen peroxide, and bundles of care have been addressed. The most convincing evidence came from interventions directly addressed against the key factors of MDR-VAP pathogenesis, especially when they are jointly implemented into bundles. Further research, however, is warranted to identify the most effective combination.

Measuring endotracheal tube intracuff pressure: no room for complacency

Tracheal intubation constitutes a routine part in the care of critically ill and anaesthetised patients. Prolonged use of endotracheal with inflated cuff is one of the major multifactorial causes of complications. Both under-inflation and over-inflation of cuff are associated with complications. Despite known problems, regular measurement of cuff pressure is not routine, and it is performed on an ad hoc basis.

Subglottic secretion drainage for preventing ventilator-associated pneumonia: an overview of systematic reviews and an updated meta-analysis

Although several guidelines recommend subglottic secretion drainage as a strategy for prevention of ventilator-associated pneumonia (VAP), its use is not widespread. With the aim to assess the effectiveness of subglottic secretion drainage for preventing VAP and to improve other outcomes such as mortality, duration of mechanical ventilation and length of stay in the intensive care unit (ICU) or hospital, an electronic search of the Cochrane Library, MEDLINE, Web of Science and Embase was undertaken. Nine systematic reviews with meta-analysis (in the overview of reviews) and 20 randomised controlled trials (in the updated meta-analysis) were included.

In the overview of reviews, all systematic reviews with meta-analysis included found a positive effect of subglottic secretion drainage in the reduction of incidence of VAP. In the updated meta-analysis, subglottic secretion drainage significantly reduced VAP incidence (risk ratio (RR) 0.56, 95% CI 0.48–0.63; I²=0%, p=0.841) and mortality (RR 0.88, 95% CI 0.80–0.97; I²=0%, p=0.888).

This is the first study that has found a decrease of mortality associated with the use of subglottic secretion drainage. In addition, subglottic secretion drainage is an effective measure to reduce VAP incidence, despite not improving the duration of mechanical ventilation and ICU and/or hospital length of stay.

Subglottic secretion drainage is an effective measure to reduce mortality and VAP incidence, despite not improving the duration of mechanical ventilation or length of stay in ICU and/or hospital.http://bit.ly/2PeJLR1

Airway Devices in Ventilator-Associated Pneumonia Pathogenesis and Prevention

Airway devices play a major role in the pathogenesis of microaspiration of contaminated oropharyngeal and gastric secretions, tracheobronchial colonization, and ventilator-associated pneumonia (VAP) occurrence. Subglottic secretion drainage is an effective measure for VAP prevention, and no routine change of ventilator circuit. Continuous control of cuff pressure, silver-coated tracheal tubes, low-volume low-pressure tracheal tubes, and the mucus shaver are promising devices that should be further evaluated by large randomized controlled trials. Polyurethane-cuffed, conical-shaped cuff, and closed tracheal suctioning system are not effective and should not be used for VAP prevention.

Subglottic secretion drainage for ventilator-associated pneumonia prevention: an underused efficient measure

Subglottic secretion drainage (SSD) is one of the recommended strategies to prevent ventilator-associated pneumonia (VAP) with a high level of evidence, especially regarding early-onset pneumonia. All meta-analysis found that the use of SSD reduces VAP occurrence with a relative risk (RR) reduction of 45%. In some of them, SSD reduces the duration of mechanical ventilation (MV) but without beneficial effect on intensive care unit (ICU) or hospital mortality. In spite of the edited recommendations, SSD has not been widely implemented in ICUs and remains underused. Several factors could account for this: doubts on the innocuousness of using SSD, persisting reservations on the SSD effect on other outcomes than VAP, a high variability in the volume of secretions suctioned between patients and, for each individual patient, during the period of MV and the initial increased expense of the specific endotracheal tubes (ETs) allowing SSD which limits the availability of these devices.

Cost of treating ventilator-associated pneumonia post cardiac surgery in the National Health Service: Results from a propensity-matched cohort study

Background

Ventilator-associated pneumonia is associated with significant morbidity, mortality and healthcare costs. Most of the cost data that are available relate to general intensive care patients in privately remunerated institutions. This study assessed the cost of managing ventilator-associated pneumonia in a cardiac intensive care unit in the National Health Service in the United Kingdom.

Methods

Propensity-matched study of prospectively collected data from the cardiac surgical database between April 2011 and December 2014 in all patients undergoing cardiac surgery (n = 3416). Patients who were diagnosed as developing ventilator-associated pneumonia, as per the surveillance definition for ventilator-associated pneumonia (n = 338), were propensity score matched with those who did not (n = 338). Costs of treating post-op cardiac surgery patients in intensive care and cost difference if ventilator-associated pneumonia occurred based on Healthcare Resource Group categories were assessed. Secondary outcomes included differences in morbidity, mortality and cardiac intensive care unit and in-hospital length of stay.

Results

There were no significant differences in the pre-operative characteristics or procedures between the groups. Ventilator-associated pneumonia developed in 10% of post-cardiac surgery patients. Post-operatively, the ventilator-associated pneumonia group required longer ventilation (p < 0.01), more respiratory support, longer cardiac intensive care unit (8 vs 3, p < 0.001) and in-hospital stay (16 vs 9) days. The overall cost for post-operative recovery after cardiac surgery for ventilator-associated pneumonia patients was £15,124 compared to £6295 for non-ventilator-associated pneumonia (p < 0.01). The additional cost of treating patients with ventilator-associated pneumonia was £8829.

Conclusion

Ventilator-associated pneumonia was associated with significant morbidity to the patients, generating significant costs. This cost was nearer to the lower end for the cost for general intensive care unit patients in privately reimbursed systems.

[Ventilator-associated pneumonia (VAP) : A risk already at the time of anesthetic induction]

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most common and preventable infections in mechanically ventilated patients. It is associated with a high mortality rate. To prevent VAP, various strategies address this issue using "VAP-bundles", which are implemented in many intensive care units. The risk of acquiring VAP starts with the induction of anesthesia, strictly speaking at the time of intubation. This article considers measures to prevent VAP during general anesthesia in adult patients (>18 years). Procedures beyond standard hygienic precautions for VAP prevention are reviewed.

METHODS

A literature search in different databases (PubMed, Cochrane, Ovid und CINAHL) over the last five years.

RESULTS

Beyond standard hygienic precautions, microaspiration should be avoided to prevent VAP. During mechanical ventilation at least 5 cm H₂O PEEP is advised. Continuous monitoring and adjustment of cuff pressure is necessary. All patients mechanically ventilated after general anesthesia for more than 24 h should be intubated with an ETT with a port for subglottic suctioning.

Microbiome, biofilms, and pneumonia in the ICU

PURPOSE OF REVIEW

Lower respiratory tract infections remain one of the leading causes of death in the world. Recently, the introduction of molecular methods based on DNA sequencing and microarrays for the identification of nonculturable microorganisms and subspecies variations has challenged the previous 'one bug - one disease' paradigm, providing us with a broader view on human microbial communities and their role in the development of infectious diseases. The purpose of this review is to describe recent understanding of the role of microbiome and bacterial biofilm in the development of lung infections, and, at the same time, to present new areas of research opportunities.

RECENT FINDINGS

The review describes recent literature in cystic fibrosis patients, chronic obstructive pulmonary disease patients, and literature in mechanically ventilated patients that helped to elucidate the role of microbiome and biofilm formation in the development of pneumonia.

SUMMARY

The characterization of the human microbiome and biofilms has changed our understanding of lower respiratory tract infections. More comprehensive, sensitive, and fast methods for bacterial, fungal, and viral detection are warranted to establish the colonization of the lower respiratory tract in healthy individuals and sick patients. Future research might explore the global bacterial, fungal, and viral pulmonary ecosystems and their interdependence to target novel preventive approaches and therapeutic strategies in chronic and acute lung infections.

Subglottic secretion suction for preventing ventilator-associated pneumonia: an updated meta-analysis and trial sequential analysis

Background

Potential benefits of subglottic secretion suction for preventing ventilator-associated pneumonia (VAP) are not fully understood.

Methods

We searched Cochrane Central, PubMed, and EMBASE up to March 2016 to identify randomized controlled trials (RCTs) that compared subglottic secretion suction versus non-subglottic secretion suction in adults with mechanical ventilation. Meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. The primary outcome was incidence of VAP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the level of evidence.

Results

Twenty RCTs (N = 3544) were identified. Subglottic secretion suction was associated with reduction of VAP incidence in four high quality trials (relative risk (RR) 0.54, 95 % confidence interval (CI) 0.40–0.74; p < 0.00001) and in all trials (RR = 0.55, 95 % CI 0.48– 0.63; p < 0.00001). Sensitivity analyses did not show differences in the pooled results. Additionally, the results of the above-mentioned analyses were confirmed in TSA. GRADE level was high. Subglottic secretion suction significantly reduced incidence of early onset VAP, gram-positive or gram-negative bacteria causing VAP, and duration of mechanical ventilation. It delayed the time-to-onset of VAP. However, no significant differences in late onset VAP, intensive care unit (ICU) mortality, hospital mortality, or ICU length of stay were found.

Conclusions

Subglottic secretion suction decreased VAP incidence and duration of mechanical ventilation and delayed VAP onset. However, subglottic secretion suction did not reduce mortality and length of ICU stay. Subglottic secretion suction is recommended for preventing VAP and for reducing ventilation length, especially in the population at high risk of early onset VAP.

Trial registration

A protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42015015715); registered on 5 January 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1527-7) contains supplementary material, which is available to authorized users.

Continuous control of tracheal cuff pressure for VAP prevention: a collaborative meta-analysis of individual participant data

Background

Underinflation of tracheal cuff is a risk factor for microaspiration of contaminated secretions and subsequent ventilator-associated pneumonia (VAP). The aim of this collaborative meta-analysis of individual participant data is to determine the impact of continuous control of P_cuff on the incidence of VAP.

Methods

Studies were identified by searching PubMed and references of relevant articles. Data from 3 prospective controlled trials (two randomized and one quasi-randomized), which evaluated the impact of continuous control of P_cuff on the incidence of VAP, were obtained and pooled together. Three different devices were used to continuously control P_cuff. VAP was diagnosed using clinical, radiologic, and quantitative microbiological criteria. The impact of continuous control of P_cuff on VAP was assessed by Cox regression analysis, stratified on trial.

Results

263 (48.4 %) patients received continuous control of P_cuff, and 280 (51.5 %) patients received routine control of P_cuff using a manometer. 36 (13.6 %) VAP were diagnosed in continuous control group, and 72 (25.7 %) in routine care group (HR 0.47, 95 % CI 0.31–0.71, p < 0.001). However, heterogeneity was apparent in continuous control effect size across trials (I² = 58 %, p = 0.085). The number of patients needed to treat to prevent one VAP episode was 8. No significant impact of continuous control of P_cuff was found on duration of mechanical ventilation, ICU length of stay, or mortality.

Conclusion

Continuous control of P_cuff might be beneficial in reducing the risk for VAP. However, no significant impact of continuous control of P_cuff was found on duration of mechanical ventilation, ICU length of stay, or mortality.