You are on page 1of 10

Review Article

Prevention of hospital-associated pneumonia and


ventilator-associated pneumonia
Marin H. Kollef, MD

Objective: To synthesize the available clinical data for the care unit staffing, avoidance of tracheal intubation with the use of
prevention of hospital-associated pneumonia (HAP) and ventila- mask ventilation, application of weaning protocols and optimal
tor-associated pneumonia (VAP) into a practical guideline for use of sedation to shorten the duration of mechanical ventilation,
clinicians. semirecumbent positioning, minimization of gastric distension,
Data Source: A Medline database and references from identi- subglottic suctioning, avoidance of ventilator circuit changes/
fied articles were used to perform a literature search relating to manipulation, routine drainage of ventilator circuit condensate).
the prevention of HAP/VAP. Clinicians caring for patients at risk for HAP/VAP should promote
Conclusions: There is convincing evidence to suggest that the development and application of local programs encompassing
specific interventions can be employed to prevent HAP/VAP. The these interventions based on local resource availability, occur-
evidence-based interventions focus on the prevention of aerodi- rence rates of HAP/VAP, and the prevalence of infection due to
gestive tract colonization (avoidance of unnecessary antibiotics antibiotic-resistant bacteria (Pseudomonas aeruginosa, Acineto-
and stress ulcer prophylaxis, use of sucralfate for stress ulcer bacter species, and methicillin-resistant Staphylococcus aureus).
prophylaxis, chlorhexidine oral rinse, selective digestive decon- (Crit Care Med 2004; 32:1396 –1405)
tamination, short-course parenteral prophylactic antibiotics in KEY WORDS: hospital-acquired pneumonia; pneumonia; ventila-
high-risk patients) and the prevention of aspiration of contami- tor-associated pneumonia; intensive care unit; nosocomial infec-
nated secretions (preferred oral intubation, appropriate intensive tion

B y definition, hospital-acquired sociated with HAP/VAP, and the reported disposing to the aspiration of contami-
pneumonia (HAP) includes hospital mortality rates for HAP/VAP nated secretions and fluids (e.g., ventila-
any case of pneumonia that range from 20% to 70% (3–7). Although tor tubing condensate) (14 –17) (Fig. 1).
starts ⱖ48 hrs after hospital patients with HAP/VAP are generally Additionally, risk profiles for the develop-
admission. Among intubated and me- sicker than those without the infection, it ment HAP/VAP have been developed to
chanically ventilated patients, the devel- is not simply a marker for other fatal identify patients at high risk for this nos-
opment of HAP 48 hrs or later is known illnesses in these patients. “Attributable ocomial infection (18). The use of such
as ventilator-associated pneumonia mortality” in patients with HAP/VAP can risk profiles can assist in targeting pre-
(VAP). There are approximately 300,000 account for up to 50% of all mortality (8, ventive strategies, especially in the set-
cases of HAP annually in the United 9). Additionally, the occurrence of HAP/ ting of limited resources.
States, representing roughly five to ten VAP has been associated with excess med-
Oropharyngeal or tracheobronchial
cases per 1,000 hospital admissions (1). ical care costs ranging from $5,800 to
colonization with pathogenic bacteria be-
Based on data from ⬎14,000 intensive $20,000 per case of HAP/VAP (10 –13).
gins with the adherence of microorgan-
care unit patients in the U.S. National
Nosocomial Infection Surveillance Sys- isms to epithelial cells in the upper and
tem, HAP is the second most common Pathogenesis of HAP/VAP lower airway (19 –24). In addition to oro-
nosocomial infection after urinary tract pharyngeal and tracheobronchial coloni-
An understanding of the pathogenesis zation, the stomach has been postulated
infection, affecting approximately 27% of
of HAP/VAP is fundamental for the devel- to be an important reservoir of organisms
all critically ill patients (2).
opment of strategies aimed at preventing that cause HAP/VAP, although the exact
HAP is the leading cause of mortality
this nosocomial infection. Risk for HAP/ role of the stomach in the causation of
attributed to nosocomial infections (2).
VAP is determined in part by the duration HAP/VAP is debated (25). The importance
Approximately 60% of all deaths in pa-
of exposure to the health care environ-
tients with nosocomial infections are as- of the stomach as a source of pathogens
ment and the presence of host factors and
for HAP/VAP appears to be influenced by
treatment-related factors that predispose
multiple factors including the use of
to the development of HAP/VAP (Table 1).
From the Pulmonary and Critical Care Division,
These risk factors predispose to the oc- medications predisposing to bacterial col-
Washington University School of Medicine, St. Louis, onization (antibiotics, stress ulcer pro-
MO. currence of HAP/VAP by increasing the
Copyright © 2004 by the Society of Critical Care likelihood for colonization of the aerodi- phylaxis), supine head positioning, the
Medicine and Lippincott Williams & Wilkins gestive tract with pathogenic bacteria administration of enteral feedings, and
DOI: 10.1097/01.CCM.0000128569.09113.FB (e.g., prior antibiotic exposure) and pre- the patient’s severity of illness to include

1396 Crit Care Med 2004 Vol. 32, No. 6


hemodynamic instability and the require- The relative importance of oropharyn- aeruginosa, Enterobacter species, Kleb-
ment for vasopressors (14, 25). geal colonization over that of gastric col- siella pneumoniae, Acinetobacter spe-
onization in the development of VAP has cies, and methicillin-resistant Staphylo-
been strongly suggested in studies using coccus aureus (31–33). Anaerobic
Table 1. Risk factors predisposing to hospital- rigorous culture methods to sequence bacteria seem to play a very limited role
associated and ventilator-associated pneumoniaa bacterial colonization in these locations in VAP, although they appear to be com-
and their relationship to VAP (26, 27). monly associated with aspiration pneu-
Witnessed aspirationb Bacteria can also gain entry into the monia in nonintubated patients (34, 35).
Chronic obstructive pulmonary diseasec
Administration of antacids or histamine type-2
lower respiratory tract of patients
antagonistsc through inhalation of aerosols generated
primarily by contaminated nebulization Nonpharmacologic Approaches
Supine positioningb
Comab devices (28). When this occurs, it is usu- to Prevent HAP/VAP
Enteral nutritionb ally related to lapses in proper infection
Nasogastric tubeb In general, nonpharmacologic ap-
Reintubationb
control procedures (29, 30).
proaches to the prevention of HAP/VAP
Tracheostomyb,c are more easily applied compared with
Patient transportb
Acute respiratory distress syndromeb,c Pathogens pharmacologic approaches and may be
Prior antibiotic exposurec performed at less expense. Additionally,
Age ⬎60 yrsc Infectious organisms that commonly the nonpharmacologic approaches usu-
Head traumab result in HAP are generally different from ally target the prevention of aspiration
Presence of intracranial pressure monitoringb
those that are most commonly associated whereas pharmacologic approaches focus
a
These risk factors are associated with hospital- with community-acquired pneumonia. on the prevention of colonization with
associated pneumonia by logistic regression analy- Gram-negative aerobes comprise the ma- pathogenic bacteria (Fig. 2) (14, 36).
sis (Ref. 17); bpredispose to aspiration of contami- jority of HAP infections (2); the individ- Avoidance of Tracheal Intubation/
nated secretions; cpredispose to colonization of the ual organisms that are commonly associ- Noninvasive Positive Pressure Ventila-
aerodigestive tract with pathogenic bacteria. ated with HAP/VAP are Pseudomonas tion. Intubation and mechanical ventila-

Figure 1. Pathogenesis of bacterial hospital-associated and ventilator-associated pneumonia.

Crit Care Med 2004 Vol. 32, No. 6 1397


was compared with that of a conventional
endotracheal tube (55–58). Although the
four randomized, controlled studies
showed a beneficial effect of continuous
suctioning of subglottic secretions on the
incidence of VAP, none of the studies
showed a corresponding effect on mortal-
ity rate, length of stay in the intensive
care unit, or duration of mechanical ven-
tilation.
Oral (Nonnasal) Intubation. Nasotra-
cheal intubation has been identified as a
risk factor promoting the development of
VAP and sinusitis (59, 60). Nasal obstruc-
tion with an endotracheal tube or feeding
tube prevents the clearance of secretions
from the sinuses resulting in the devel-
opment of sinusitis. Aspiration of infected
secretions from the sinuses into the
lower respiratory tract can overwhelm lo-
cal host defense mechanisms allowing
Figure 2. The relationship between pathogenesis and preventive strategies for hospital-associated VAP to occur (61). Available investiga-
pneumonia (HAP) and ventilator-associated pneumonia (VAP). *Prevention strategies that should be
tions and experience suggest that the pre-
limited to specific patient populations according to available clinical data.
ferred route of tracheal and gastric intu-
bation is via the oropharynx and not the
tion are, by definition, prerequisites for tration of sedation (45) and accelerated nasopharynx to prevent both hospital-
the development of VAP. Unnecessary in- weaning from mechanical ventilation us- associated sinusitis and HAP/VAP.
tubation, therefore, should be avoided at ing either weaning protocols or early at- Avoid Unnecessary Manipulation/
all times. Noninvasive positive-pressure tempts at spontaneous breathing (46). Changes of the Ventilator Circuit. The
ventilation using a full-face or nasal mask The goal of these strategies is to mini- role of ventilator tubing changes in pre-
can be used as an alternative ventilation mize the patient’s exposure to endotra- venting pneumonia among mechanically
mode in many patients with acute respi- cheal intubation with its inherent risk of ventilated patients has been extensively
ratory failure. The beneficial effects of aspiration of contaminated secretions. investigated. Initial studies evaluating
noninvasive positive-pressure ventilation Appropriate Staffing Levels in the In- contamination of mechanical ventilator
on the development of VAP and patient tensive Care Unit. Nursing and respira- circuits with heated water humidifiers
survival have been determined in ran- tory therapy staffing levels may influence have shown that neither the rate of bac-
domized trials for patients with various the length of stay of patients in intensive terial contamination of inspiratory-phase
medical conditions including acute exac- care units, with an inverse relationship gas nor the incidence of pneumonia was
erbations of chronic obstructive pulmo- between the adequacy of staffing levels significantly increased when tubing was
nary disease and acute lung injury with and duration of stay and subsequent de- changed more frequently (62, 63). This
hypoxic respiratory failure and in immu- velopment of HAP/VAP (47, 48). With in- finding has been confirmed in more re-
nosuppressed patients with pulmonary creased workloads for registered nurses cent observational and randomized trials
infiltrates and respiratory failure (37– and the reliance on less trained health (64 – 67). Therefore, the previous recom-
41). The beneficial influence of noninva- care personnel for the delivery of care, mendations of the Centers for Disease
sive positive-pressure ventilation on VAP there is concern that lapses in infection Control to change ventilator circuits rou-
and hospital mortality rate has been fur- control will occur, resulting in greater tinely on the basis of duration of use
ther demonstrated in a recent large ob- rates of nosocomial infection (49 –53). should be changed to one that is based on
servational study of patients experiencing Availability of staff to participate in man- visual contamination of the ventilator
exacerbations of chronic obstructive pul- datory training aimed at preventing HAP/ circuit with blood, emesis, or purulent
monary disease and pulmonary edema VAP appears to also be important for the secretions (68). This change may reduce
(42). prevention of this nosocomial infection the overall occurrence of VAP, minimize
Shortening the Duration of Mechani- (16). health care exposure to infectious aero-
cal Ventilation. Several studies have Subglottic Suctioning. Secretions are sols that occur with circuit manipulation,
identified an association between the du- common in the upper airways of intu- and result in cost savings.
ration of mechanical ventilation and the bated patients. Additionally, secretions Drain Ventilator Circuit Condensate/
development of VAP (43, 44). As a result, appear to pool above the endotracheal Use of Heat and Moisture Exchangers.
strategies to reduce patient exposure to tube cuff allowing for leakage of contam- The contaminated condensate within
this risk factor may decrease the risk for inated secretions into the lower airway ventilator circuits may predispose to
development of VAP. Examples of strate- (54). In four studies, the effect of using an HAP/VAP and serve as a reservoir for the
gies with the potential to shorten the endotracheal tube that has a separate spread of nosocomial pathogens through-
duration of mechanical ventilation are dorsal lumen, which allows continuous out an intensive care unit (69). Based on
protocols aimed at limiting the adminis- aspiration of the subglottic secretions, these observations, a scheduled approach

1398 Crit Care Med 2004 Vol. 32, No. 6


to the removal of tubing condensate, with tration of intragastric feeding solutions, in intensive critical units. Transmission
its proper disposal, should be employed using gastrointestinal motility agents, of these microorganisms to patients fre-
in all treatment areas where patients re- supplying enteral nutrition with smaller quently occurs via health care person-
ceive mechanical ventilation. The trans- bore feeding tubes, and administering nel’s hands that become contaminated or
port of contaminated condensate from feeding solutions directly into the small transiently colonized with the microor-
one patient room to an another within a bowel instead of the stomach (14, 15). ganisms. Procedures such as tracheal
common collection container should be A recent analysis examined ten studies suctioning and manipulation of ventila-
avoided as this can result in outbreaks of comparing gastric feeding with small tor circuits or endotracheal tubes in-
VAP due to antibiotic-resistant bacteria bowel feeding of critically ill patients crease the opportunity for cross-contam-
(16). Condensate accumulation can be re- (81). In general, this analysis found that ination with these pathogens. The risk of
duced to a great extent with the applica- small bowel feeding was associated with a cross-contamination can be reduced by
tion of heat and moisture exchangers, reduction in gastroesophageal regurgita- using aseptic technique and sterile or dis-
thereby potentially reducing the risk of tion, an increase in protein and calories infected equipment when appropriate and
VAP (70, 71). This may explain the lower delivery to patients, and a shorter time to eliminating pathogens from the hands of
incidence of late-onset VAP observed in achieving the target dose of nutrition. personnel. The use of alcohol-based
one randomized trial comparing humid- Compared with gastric feeding, when the foams and lotions allows hand disinfec-
ification with a heat and moisture ex- results of seven randomized trials were tion to occur more efficiently (90, 91).
changer compared with conventional aggregated statistically, small bowel feed- The use of these methods has been advo-
heat-water humidification (72). Routine ing was associated with an overall reduc- cated as a means to increase compliance
monitoring of all ventilator circuits for tion in pneumonia (81). However, there among health care providers with hand
the accumulation of condensate and ex- was no difference in mortality rates be- disinfection before patient contacts (92).
peditious removal of condensate are im- tween the two groups. However, delaying
portant measures to prevent the develop- the administration of enteral feedings in
ment of VAP. some patient may also prevent the occur- Pharmacologic Approaches
Semierect Positioning. Aspiration of rence of HAP/VAP (82).
upper airway secretions is a common Biofilm Prevention Technology. Bio- Avoid Unnecessary Use of Stress Ulcer
event even in normal healthy adults (73). films form on surfaces such as an endo- Prophylaxis. Both histamine type-2 an-
Among mechanically ventilated patients, tracheal tube when they are encountered tagonists and antacids are recognized to
supine positioning has been shown to be by bacteria that “settle” on that surface, be appropriate measures for stress ulcer
an independent risk factor for the devel- up-regulating genes involved in matrix prophylaxis and risk factors for VAP (93–
opment of VAP (74). Studies employing production (83). The colonies of bacteria 95). The risk of VAP is increased by de-
radiolabeled enteral feeding solutions in forming the biofilm and detaching from creasing intragastric acidity, which can
ventilated patients have demonstrated it are under the control of chemical sig- result in greater gastric colonization with
that aspiration of gastric contents occurs nals of the same type that regulates pathogenic bacteria. Additionally, intra-
to a significantly greater degree when pa- quoron sensing, and these regulatory gastric volumes may be increased with
tients are in the supine position com- molecules guide the formation of the the administration of antacids promoting
pared with the semirecumbent position slime-enclosed microcolonies and water aspiration and the development of VAP.
(75–77). One randomized trial demon- channels that makeup the biofilm (84). Sucralfate has been advocated as an alter-
strated a three-fold reduction in the inci- Certain bacteria such as Pseudomonas native, but potentially less active, agent
dence of VAP and a trend toward a re- species appear to be more capable of for stress ulcer prophylaxis that does not
duced hospital mortality rate in patients forming biofilms, especially in the pres- decrease intragastric acidity and does not
treated in the semirecumbent position ence of abnormal airway mucosa as exists increase gastric volume significantly
(maintained at 45°) compared with pa- in patients with cystic fibrosis (24). The (96 –98).
tients treated completely supine (78). Of recognition of biofilms on the surface of Decolonization of the Aerodigestive
note, the occurrence of VAP among pa- endotracheal tubes has resulted in the Tract. Colonization of the upper respira-
tients in the supine position was strongly development of other novel approaches tory tract is an important prerequisite for
associated with the simultaneous admin- aimed at limiting their formation. These the development of VAP. Oropharyngeal
istration of enteral nutrition. include the use of surface coatings that colonization, either present on admission
Avoidance of Large Gastric Volumes. impede bacterial adherence, oxygen- or acquired during hospitalization, has
Several studies have found an association plasma processing of the polyvinyl chlo- been identified as an independent risk
between the aspiration of gastric contents ride, and the administration of nebulized factor for the development of VAP caused
and VAP, suggesting that the avoidance of antibiotics (84 – 89). Unfortunately, none by enteric Gram-negative bacteria and P.
gastric overdistention may reduce the oc- of these approaches has been subjected to aeruginosa (98). Modulation of oropha-
currence of this complication (79, 80). clinical investigation, and it is also not ryngeal colonization, either with antibi-
Unfortunately, the optimal approach for clear whether such technologies will in- otics (99 –102) or chlorhexidine (103),
providing nutrition to mechanically ven- fluence the adherence of airway secre- appears to be an effective measure to pre-
tilated patients remains undefined. Cur- tions on the surface of endotracheal vent VAP. However, the main limitation
rently available measures aimed at avoid- tubes. to the routine use of these agents has
ing gastric overdistention include Hand Washing/Disinfection. Patho- been the emergence of bacterial resis-
reducing the use of narcotics and anti- gens causing HAP/VAP, such as Gram- tance (104). Therefore, oropharyngeal de-
cholinergic agents, monitoring gastric negative bacilli and S. aureus, are ubiq- contamination has been limited to spe-
residual volumes following the adminis- uitous in health care settings, especially cific populations at high risk for VAP and

Crit Care Med 2004 Vol. 32, No. 6 1399


to control outbreaks of antibiotic-resis- quate empirical antimicrobial coverage is use of a vaccine directed against a respi-
tant bacteria (105). the practice of a scheduled antibiotic ratory pathogen in a high-risk population
Selective decontamination of the di- class switch (113, 114). This strategy has reduced subsequent hospitalization for
gestive tract (SDD) combines oropharyn- been associated with reductions in the pneumonia, supporting the benefit of this
geal decontamination with gastric decon- occurrence of VAP when increasing intervention (126). Unfortunately, vac-
tamination and systemic administration emergence of resistance to the baseline cines directed against the pathogens as-
of antimicrobials. Several recent meta- antibiotic class was recognized as the sociated with HAP/VAP possessing long-
analyses have demonstrated that the use stimulus for the drug class switch (113). term efficacy are not currently available
of SDD is associated with significant re- However, more general strategies pro- for clinical use (127).
ductions in the incidence of VAP and moting antimicrobial heterogeneity (i.e., Avoidance of Red Blood Cell Transfu-
lower rates of hospital mortality, espe- antibiotic cycling, antibiotic rotation) sions. The transfusion of packed red
cially among surgical patients (106, 107). should only be employed as part of a blood cells has been associated with seri-
A recent study of SDD among surgical wider effort aimed at preventing antimi- ous nosocomial infections including VAP
patients with a low prevalence of coloni- crobial resistance. This recommendation (18, 128 –130). In one study, transfusion
zation with resistant bacteria (e.g., van- is based on the inconsistent results re- of packed red blood cells was found to be
comycin-resistant enterococci, methicil- garding the influence of these practices an independent risk factor for the devel-
lin-resistant S. aureus) found a on antimicrobial resistance and the oc- opment of VAP (131). These data suggest
statistically significant reduction in mor- currence of nosocomial infections includ- that the unnecessary transfusion of
tality rate without increasing overall col- ing HAP/VAP (114 –117). Practices focus- packed red blood cells should be avoided
onization with resistant bacteria (108). ing on antimicrobial heterogeneity in hospitalized patients in order to reduce
However, like with antimicrobial oropha- without the application of other strate- the risk of nosocomial infections includ-
ryngeal decontamination, SDD carries gies aimed at preventing the emergence ing HAP/VAP.
the potential risk of promoting more of antibiotic-resistant infections (e.g.,
widespread antibiotic resistance (109). short-course antibiotic therapy, appropri- Barriers to Implementation of
Therefore, the use of SDD should be care- ate hand disinfection) have the risk of Prevention Strategies
fully monitored for the emergence of an- simply increasing resistance to subse-
timicrobial resistance. quently introduced antimicrobial drug Although the prevention of hospital-
Prophylactic Antibiotics. A recent classes (112, 118). associated infections, including HAP/
study found that prolonged use of pro- Shorter Courses of Empirical Antibi- VAP, is advocated as an important man-
phylactic antibiotics in trauma patients otic Therapy. Shortening the duration of agement objective for all hospitals,
was associated with the delayed onset of empirical antibiotic therapy may be a barriers exist to the implementation of
HAP/VAP, an increased incidence of valuable approach for reducing subse- such interventions. Cook et al. (132)
pneumonia caused by antibiotic-resistant quent hospital-associated infections, in- compared Canadian and French intensive
Gram-negative bacteria, and an increased cluding HAP/VAP, that are caused by an- care units regarding the use of seven
overall incidence of nosocomial infec- tibiotic-resistant bacteria (119 –121). strategies to control secretions and care
tions (110). This study confirms the po- Recently, the results of a large random- for ventilator circuits to prevent VAP and
tential harm of prolonged prophylactic ized trial comparing 8 days of adequate reduce overall health care costs. Adher-
antibiotics and suggests that the duration antibiotic therapy for VAP to 15 days of ence to specific prevention guidelines for
of prophylactic therapy in this patient treatment were reported (122). Despite VAP was statistically more common
population must be critically reevaluated similar efficacy, the longer course of an- among French intensive care units (64%
because it may have a significant impact tibiotic therapy was associated with sta- vs. 30%, p ⫽ .002), but rates were low in
on the infectious morbidity and the costs tistically greater emergence of multiply both countries. These investigators also
associated with the care of trauma pa- resistant bacteria. These data suggest found that published recommendations
tients. However, prophylactic parenteral that shorter empirical courses of antibi- did not appear to substantially affect
antibiotics may play a role in the preven- otic therapy for VAP and other infections whether prevention interventions were
tion of HAP/VAP among specific high-risk are safe and can decrease the emergence used within individual intensive care
populations including patients with head of bacterial resistance and subsequent in- units. Similarly, two European surveys
trauma or coma (111). Therefore, pro- fections due to antibiotic-resistant bacte- conducted among physicians and nurses,
phylactic antibiotics should be employed ria (122, 123). respectively, found that 37.0% of inten-
in appropriate high-risk patients (e.g., Vaccines. Various vaccination pro- sive care unit physicians and 22.3% of
trauma, severe head injury, coma, high- grams in adults and children have been nurses were not following published rec-
risk surgical procedures) generally for demonstrated to be successful in reduc- ommendations for the prevention of VAP
ⱕ24 hrs following surgery or the initial ing the incidence of pneumonia caused (133, 134). The most common reasons for
trauma. by specific pathogens, including Hae- nonadherence were disagreement with
Antibiotic Class Switch. Predominant mophilus influenzae, Streptococcus the interpretation of clinical trials, lack of
use of a single drug class for the treat- pneumoniae, and the influenza virus resources, fear of potential adverse
ment of Gram-negative bacterial infec- (124 –126). These pathogens are major events, and costs associated with the im-
tions has been associated with the emer- causes of health care-associated pulmo- plementation of specific interventions.
gence of antibiotic-resistant infections nary infection and can predispose pa- Cook et al. (135) also surveyed clini-
including HAP/VAP (112). One strategy tients to developing respiratory failure cians to determine the reasons for the
designed specifically to minimize antimi- and the subsequent development of HAP/ lack of use of semirecumbency to prevent
crobial resistance while ensuring ade- VAP. At least one study showed that the HAP. Nurses perceived that the main de-

1400 Crit Care Med 2004 Vol. 32, No. 6


terminant of semirecumbency was physi- fied barriers to semirecumbency related (e.g., decubitus ulcers), safety (e.g., slid-
cians’ orders, whereas intensivists per- to useful alternative positions (e.g., lat- ing out of the bed), and available re-
ceived that the main determinant was eral position), contraindications (e.g., he- sources (e.g., insufficient beds facilitating
nursing preference. Participants identi- modynamic instability), risk of harm semirecumbency). When made aware of

Table 2. Prevention protocol for hospital-associated pneumonia and ventilator-associated pneumonia (VAP) at Barnes-Jewish Hospitala

To prevent bacterial colonization of the aerodigestive tract


Meticulous hand hygiene with the use of soap and water or a waterless hand antiseptic agent is essential before and after ventilator contact or
patient suctioning.
Do not change ventilator circuits and/or in-line suction catheters unless visibly soiled or malfunctioning.
Do not use heat moisture exchangers (HMEs) for patients with excessive secretions or hemoptysis (be sure to provide alternative form of
humidification).
Change HMEs every 24 hrs or when visibly soiled with secretions.
Drain condensate from ventilator circuits per policy using appropriate technique to avoid contamination of the circuit.
To prevent aspiration of contaminated secretions
Maintain adequate ventilation and cuff pressure.
Place ventilated patients in semirecumbent position with head of bed elevated to at least 30°, as tolerated, even during transport.
Drain ventilator circuit condensate before repositioning patient.
To avoid gastric distention, monitor gastric residual volumes before initiating gastric feedings via nasogastric, orogastric, or percutaneous
gastrostomy tubes.
Remove nasogastric tubes as soon as possible.
To reduce risk of VAP when suctioning a ventilated patient
Use clean gloves for in-line suctioning and sterile gloves for single use catheter suctioning.
Do not store catheter where it can become contaminated or contaminate clean supplies.
Oral suction catheters (e.g., Yankauer) should be stored in a nonsealed paper or plastic bag when not in use.
Do not lay suction catheters on ventilator.
Suction when necessary. Frequent unnecessary suctioning may introduce organisms into the lower respiratory tract.
Other key points to reduce the risk of VAP
Avoid nasal intubation.
Adequately secure endotracheal tube and take necessary measures to prevent accidental extubation.
Avoid overuse of multiple antibiotics.
Limit stress ulcer treatment if possible.
Use daily chlorhexidine oral rinse (only for patients undergoing cardiothoracic surgery).
Provide immunizations (e.g., influenza, Pneumococcus, Haemophilus B)
a
This protocol was employed in the prevention programs described in Refs. 16 and 137.

Figure 3. Results of a mandatory education program for the prevention of hospital-associated pneumonia and ventilator-associated pneumonia (VAP) carried
out in three hospitals employing the recommendations outlined in Table 2 (137). The arrow indicates the introduction of the intervention.

Crit Care Med 2004 Vol. 32, No. 6 1401


are achievable with the available local 15. Kollef MH: The prevention of ventilator-

T
hospital resources. associated pneumonia. N Engl J Med 1999;
here is convincing 340:627– 634
16. Zack JE, Garrison T, Trovillion E, et al:
evidence to sug- REFERENCES Effect of an education program aimed at
1. McEachern R, Campbell GD Jr: Hospital- reducing the occurrence of ventilator-
gest that specific acquired pneumonia: Epidemiology, and associated pneumonia. Crit Care Med 2002;
treatment. Infect Dis Clin North Am 1998; 30:2407–2412
interventions can be em- 12:761–779 17. Cook DJ, Kollef MH: Risk factors for ICU-
2. Richards MJ, Edwards JR, Culver DH, et al: acquired pneumonia. JAMA 1998; 279:
ployed to prevent hospi- 1605–1606
Nosocomial infections in medical intensive
care units in the United States. Crit Care 18. Arozullah AM, Khuri SF, Henderson WG, et
tal-associated pneumonia al: Development and validation of a multi-
Med 1999; 27:887– 892
and ventilator-associated 3. Gross PA, Neu HC, Aswapokee P, et al: factorial risk index for predicting postoper-
Deaths from nosocomial infections: experi- ative pneumonia after major noncardiac
pneumonia. ence in a university hospital and a commu- surgery. Ann Intern Med 2001; 135:
nity hospital. Am J Med 1980; 68:219 –223 847– 857
4. Fagon J-Y, Chastre J, Domart Y, et al: Nos- 19. Johanson WG, Pierce AK, Sanford JP, et al:
ocomial pneumonia in patients receiving Nosocomial respiratory infections with
continuous mechanical ventilation: Pro- Gram-negative bacilli. The significance of
the evidence, all participants endorsed spective analysis of 52 episodes with use of colonization of the respiratory tract. Ann
the use of semirecumbency. The use of a protected specimen brush and quantita- Intern Med 1972; 77:701–706
standardized orders for patient position- tive culture techniques. Am Rev Respir Dis 20. Johanson WG, Pierce AK, Sanford JP:
ing was recently shown to increase 1989; 139:877– 884 Changing pharyngeal bacterial flora of hos-
5. Joshi N, Localio AR, Hamory BH: A predic- pitalized patients. Emergence of Gram-
awareness of the importance of this in-
tive risk index for nosocomial pneumonia in negative bacilli. N Engl J Med 1969; 281:
tervention and to increase compliance 1137–1140
the intensive care unit. Am J Med 1992;
with semirecumbency (136). 93:135–142 21. Niederman MS: Bacterial adherence as a
6. George DL: Epidemiology of nosocomial mechanism of airway colonization. Eur
CONCLUSIONS pneumonia in intensive care unit patients. J Clin Microbiol Infect Dis 1989; 8:15–20
Clin Chest Med 1995; 16:29 – 44 22. Menzies BE: The role of fibronectin binding
Although the optimal approach to re- 7. Celis R, Torres A, Gatell JM, et al: Nosoco- proteins in the pathogenesis of Staphylo-
ducing VAP is unclear, recent studies in- mial pneumonia. A multivariate analysis of coccus aureus infections. Curr Opin Infect
dicate that mandatory education of risk and prognosis. Chest 1988; 93:318 –324 Dis 2003; 16:225–229
health care workers caring for mechani- 8. Fagon J-Y, Chastre J, Hance AJ, et al: Nos- 23. Niederman MS, Merrill WW, Ferranti RD, et
cally ventilated patients can decrease ocomial pneumonia in ventilated patients: al: Nutritional status and bacterial binding
overall VAP rates (Table 2, Fig. 3) (16, A cohort study evaluating attributable mor- in the lower respiratory tract in patients
137). Among the available interventions, tality and hospital stay. Am J Med 1993; with chronic tracheostomy. Ann Intern Med
94:281–288 1984; 100:795– 800
shortening the duration of mechanical
9. Bryan CS, Reynolds KL: Bacteremic noso- 24. Prince AS: Biofilms, antimicrobial resis-
ventilation and providing measures to tance, and airway infection. N Engl J Med
comial pneumonia: Analysis of 172 episodes
prevent the aspiration of contaminated from a single metropolitan area. Am Rev 2002; 347:1110 –1101
secretions appear to be most important. Respir Dis 1984; 129:668 – 671 25. Craven DE, Steger KA, Barber TW: Prevent-
Given the evidence supporting greater 10. Boyce JM, Potter-Bynoe G, Dziobek L, et al: ing nosocomial pneumonia; state of the art
morbidity rate, hospital mortality rate, Nosocomial pneumonia in Medicare pa- and perspectives for the 1990s. Am J Med
and medical care costs among patients tients. Hospital costs and reimbursement 1991; 91:44s–53s
developing HAP/HAP, the prevention of patterns under the prospective payment 26. Bonten MJ, Gaillard CA, de Leeuw PW, et al:
this nosocomial infection should be an system. Arch Intern Med 1991; 151: Role of colonization of the upper intestinal
important priority in the hospital setting. 1109 –1114 tract in the pathogenesis of ventilator-
11. Rello J, Ollendorf DA, Oster G, et al: Epide- associated pneumonia. Clin Infect Dis 1997;
However, it is important to note that in-
miology and outcomes of ventilator-associ- 24:309 –319
terventions focusing on the prevention of 27. van Nieuwenhoven CA, Buskens E, van Tiel
ated pneumonia in a large US database.
early-onset HAP/VAP (i.e., occurring Chest 2002; 122:2115–2121 FH, et al: Relationship between method-
within the first 5 days of hospitalization) 12. Warren DK, Shukla SJ, Olsen MA, et al: ological trial quality and the effects of se-
attributed to antibiotic-sensitive bacteria Outcomes and attributable cost of ventila- lective digestive decontamination on pneu-
may not be associated with reduced mor- tor associated pneumonia among intensive monia and mortality in critically ill
tality rate, especially if these infections care unit patients in a suburban medical patients. JAMA 2001; 286:335–340
are treated with appropriate antibiotic center. Crit Care Med 2003; 31:1312–1317 28. Chastre J, Fagon JY: Ventilator-associated
regimens (14, 138). Nevertheless, clini- 13. Haley RW, White JW, Culver DH, et al: The pneumonia. Am J Respir Crit Care Med
cians caring for patients at risk for devel- financial incentive for hospitals to prevent 2002; 165:867–903
nosocomial infections under the prospec- 29. Ramsey AH, Skonieczny P, Coolidge DT, et
oping HAP/VAP should ensure that infec-
tive payment system: An empirical determi- al: Burkholderia cepacia lower respiratory
tion prevention programs are in place
nation from a nationally representative tract infection associated with exposure to a
within their hospitals. These programs sample. JAMA 1987; 257:1611–1614 respiratory therapist. Infect Control Hosp
should target HAP/VAP, as well as other 14. Kollef MH: Epidemiology and risk factors Epidemiol 2001; 22:423– 426
important hospital-associated infections, for nosocomial pneumonia. Emphasis on 30. Vassal S, Taamma R, Marty N, et al: Micro-
incorporating interventions that have prevention. Clin Chest Med 1999; 20: biologic contamination study of nebulizers
been demonstrated to be successful and 653– 670 after aerosol therapy in patients with cystic

1402 Crit Care Med 2004 Vol. 32, No. 6


fibrosis. Am J Infect Control 2000; 28: dence of and risk factors for ventilator- 60. Bert F, Lambert-Zechovsky N: Sinusitis in
347–351 associated pneumonia in critically ill pa- mechanically ventilated patients and its role
31. George DL, Falk PS, Wunderink RG, et al: tients. Ann Intern Med 1998; 129:433– 440 in the pathogenesis of nosocomial pneumo-
Epidemiology of ventilator-acquired pneu- 45. Brook AD, Ahrens TS, Schaiff R, et al: Effect nia. Eur J Clin Microbiol Infect Dis 1996;
monia based on protected bronchoscopic of a nursing-implemented sedation protocol 15:533–544
sampling. Am J Respir Crit Care Med 1998; on the duration of mechanical ventilation. 61. Holzapfel L, Chastang C, Demingeon G, et
158:1839 –1847 Crit Care Med 1999; 27:2609 –2615 al: A randomized study assessing the sys-
32. NNIS System. National Nosocomial Infec- 46. Ely EW, Meade MO, Haponik EF, et al: Me- tematic search for maxillary sinusitis in na-
tions Surveillance (NNIS) System report, chanical ventilator weaning protocols sotracheally mechanically ventilated pa-
data summary from January 1990-May driven by nonphysician health-care profes- tients. Influence of nosocomial maxillary
1999, issued June 1999. Am J Infect Control sionals: Evidence-based clinical practice sinusitis on the occurrence of ventilator-
1999; 27:520 –532 guidelines. Chest 2001; 120:454S– 463S associated pneumonia. Am J Respir Crit
33. Neuhauser MM, Weinstein RA, Rydman R, 47. Needleman J, Buerhaus P, Mattke S, et al: Care Med 1999; 159:695–701
et al: Antibiotic resistance among Gram- Nurse-staffing levels and the quality of care 62. Lareau SC, Ryan KJ, Diener CF: The rela-
negative bacilli in US intensive care units: in hospitals. N Engl J Med 2002; 346: tionship between frequency of ventilator
Implications for fluoroquinolone use. JAMA 1715–1722 circuit changes and infectious hazard. Am
2003; 289:885– 888 48. Cho SH, Ketefian S, Barkauskas VH, et al: Rev Respir Dis 1978; 118:493– 496
34. Dore P, Robert R, Grollier G, et al: Inci- The effects of nurse staffing on adverse 63. Craven DE, Connolly MG Jr, Lichtenberg
dence of anaerobes in ventilator-associated events, morbidity, mortality, and medical DA, et al: Contamination of mechanical
pneumonia with use of a protected speci- costs. Nursing Research 2003; 52:71–79 ventilators with tubing changes every 24 or
men brush. Am J Respir Crit Care Med 49. Fridkin SK, Pear SM, Williamson TH, et al: 48 hours. N Engl J Med 1982; 306:
1996; 153:1292–1298 The role of understaffing in central venous 1505–1509
35. Marik PE, Careau P: The role of anaerobes catheter-associated bloodstream infections. 64. Dreyfuss D, Djedaini K, Weber P, et al: Pro-
in patients with ventilator-associated pneu- Infect Control Hosp Epidemiol 1996; 17: spective study of nosocomial pneumonia
monia and aspiration pneumonia: A pro- 150 –158 and of patient and circuit colonization dur-
spective study. Chest 1999; 115:178 –183 50. Pittet D, Mourouga P, Perneger TV: Com- ing mechanical ventilation with circuit
36. Collard HR, Saint S, Matthay MA: Preven- pliance with handwashing in a teaching changes every 48 hours versus no change.
tion of ventilator-associated pneumonia: An hospital. Ann Intern Med 1999; 130: Am Rev Respir Dis 1991; 143:738 –743
evidence-based systematic review. Ann In- 126 –130 65. Kollef MH, Shapiro SD, Fraser VJ, et al:
tern Med 2003; 138:494 –501 51. Archibald LK, Manning ML, Bell LM, et al: Mechanical ventilation with or without
37. Girou E, Schortgen F, Delclaux C, et al: Patient density, nurse-to-patient ratio and 7-day circuit changes. A randomized con-
Association of noninvasive ventilation with nosocomial infection risk in a pediatric car- trolled trial. Ann Intern Med 1995; 123:
nosocomial infections and survival in criti- diac intensive care unit. Pediatr Infect Dis J 168 –174
cally ill patients. JAMA 2000; 284: 1997; 16:1045–1048 66. Long MN, Wickstrom G, Grimes A, et al:
2361–2367 52. Pronovost PJ, Angus DC, Dorman T, et al: Prospective, randomized study of ventila-
38. Antonelli M, Conti G, Rocco M, et al: A Physician staffing patterns and clinical out- tor-associated pneumonia in patients with
comparison of noninvasive positive-pres- comes in critically ill patients: A systematic one versus three ventilator circuit changes
sure ventilation and conventional mechan- review. JAMA 2002; 288:2151–2162 per week. Infect Control Hosp Epidemiol
ical ventilation in patients with acute respi- 53. Pronovost PJ, Jenckes MW, Dorman T, et al: 1996; 17:14 –19
ratory failure. N Engl J Med 1998; 339: Organizational characteristics of intensive 67. Hess D, Burns E, Romagnoli D, et al:
429 – 435 care units related to outcomes of abdominal Weekly ventilator circuit changes. A strat-
39. Nava S, Ambrosino N, Clini E, et al: Nonin- aortic surgery. JAMA 1999; 281:1310 –1317 egy to reduce costs without affecting pneu-
vasive mechanical ventilation in the wean- 54. Greene R, Thompson S, Jantsch HS, et al: monia rates. Anesthesiology 1995; 82:
ing of patients with respiratory failure due Detection of pooled secretions above endo- 903–911
to chronic obstructive pulmonary disease. A tracheal tube cuffs: Value of plain radio- 68. Tablan OC, Anderson LJ, Arden NH, et al:
randomized, controlled trial. Ann Intern graphs in sheep and patients. Am J Roent- Guideline for prevention of nosocomial
Med 1998; 128:721–728 genol 1994; 163:1333–1337 pneumonia. The Hospital Infection Control
40. Hilbert G, Gruson D, Vargas F, et al: Non- 55. Mahul P, Auboyer C, Jospe R, et al: Preven- Practices Advisory Committee, Centers for
invasive ventilation in immunosuppressed tion of nosocomial pneumonia in intubated Disease Control and Prevention. Infect Con-
patients with pulmonary infiltrates, fever, patients: Respective role of mechanical sub- trol Hosp Epidemiol 1994; 15:587– 627
and acute respiratory failure. N Engl J Med glottic secretions drainage and stress ulcer 69. Craven DE, Goularte TA, Make BJ: Contam-
2001; 344:481– 487 prophylaxis. Intensive Care Med 1992; 18: inated condensate in mechanical ventilator
41. Antonelli M, Conti G: Noninvasive positive 20 –25 circuits. A risk factor for nosocomial pneu-
pressure ventilation as treatment for acute 56. Valles J, Artigas A, Rello J, et al: Continuous monia?. Am Rev Respir Dis 1984; 129:
respiratory failure in critically ill patients. aspiration of subglottic secretions in pre- 625– 628
Crit Care 2000; 4:15–22 venting ventilator-associated pneumonia. 70. Dreyfuss D, Djedaini K, Gros I, et al: Me-
42. Girou E, Brun-Buisson C, Taille S, et al: Ann Intern Med 1995; 122:179 –186 chanical ventilation with heated humidifi-
Secular trends in nosocomial infections and 57. Kollef MH, Skubas NJ, Sundt TM: A ran- ers or heat and moisture exchangers: Ef-
mortality associated with noninvasive ven- domized clinical trial of continuous aspira- fects on patient colonization and incidence
tilation in patients with exacerbations of tion of subglottic secretions in cardiac sur- of nosocomial pneumonia. Am J Respir Crit
COPD and pulmonary edema. JAMA 2003; gery patients. Chest 1999; 116:1339 –1346 Care Med 1995; 151:986 –992
290:2985–2991 58. Smulders K, van der HH, Weers-Pothoff I, 71. Saravolatz LD, Pohlod DJ, Conway W, et al:
43. Ibrahim EH, Tracy L, Hill C, et al: The et al: A randomized clinical trial of inter- Lack of bacterial aerosols associated with
occurrence of ventilator-associated pneu- mittent subglottic secretion drainage in pa- heat and moisture exchangers. Am Rev Re-
monia in a community hospital: Risk fac- tients receiving mechanical ventilation. spir Dis 1986; 134:214 –216
tors and clinical outcomes. Chest 2001; Chest 2002; 121:858 – 862 72. Kirton OC, DeHaven B, Morgan J, et al: A
120:555–561 59. Holzapfel L: Nasal vs oral intubation. Min- prospective, randomized comparison of an
44. Cook DJ, Walter SD, Cook RJ, et al: Inci- erva Anestesiologica 2003; 69:348 –352 in-line heat moisture exchange filter and

Crit Care Med 2004 Vol. 32, No. 6 1403


heated wire humidifiers: Rates of ventilator- of respiratory bacterial pathogens. Pharm Am J Respir Crit Care Med 1996; 154:
associated early-onset (community-ac- Res 2002; 19:818 – 824 1339 –1346
quired) or late-onset (hospital-acquired) 87. Yanagihara K, Tomono K, Imamura Y, et al: 99. Bergmans DC, Bonten MJ, Gaillard CA, et
pneumonia and incidence of endotracheal Effect of clarithromycin on chronic respira- al: Prevention of ventilator-associated
tube occlusion. Chest 1997; 112:1055–1059 tory infection caused by Pseudomonas pneumonia by oral decontamination: a pro-
73. Huxley EJ, Viroslav J, Gray WR, et al: Pha- aeruginosa with biofilm formation in an spective, randomized, double-blind, place-
ryngeal aspiration in normal adults and pa- experimental murine model. J Antimicrob bo-controlled study. Am J Respir Crit Care
tients with depressed consciousness. Am J Chemother 2002; 49:867– 870 Med 2001; 164:382–388
Med 1978; 64:564 –568 88. Triandafillu K, Balazs DJ, Aronsson BO, et 100. Abele-Horn M, Dauber A, Bauernfeind A, et
74. Kollef MH: Ventilator-associated pneumo- al: Adhesion of Pseudomonas aeruginosa al: Decrease in nosocomial pneumonia in
nia: A multivariate analysis. JAMA 1993; strains to untreated and oxygen-plasma ventilated patients by selective oropharyn-
270:1965–1970 treated poly (vinyl chloride) (PVC) from en- geal decontamination. Intensive Care Med
75. Ibanez J, Penafiel A, Raurich JM, et al: Gas- dotracheal intubation devices. Biomaterials 1996; 23:187–195
troesophageal reflux in intubated patients 2003; 24:1507–1518 101. Pugin J, Auckenthaler R, Lew DP, et al:
receiving enteral nutrition: Effect of supine 89. Adair CG, Gorman SP, Byers LM, et al: Oropharyngeal decontamination decreases
and semirecumbent positions. JPEN 1992; Eradication of endotracheal tube biofilm by incidence of ventilator-associated pneumo-
16:419 – 422 nebulized gentamicin. Intensive Care Med nia: A randomized, placebo-controlled, dou-
76. Orozco-Levi M, Torres A, Ferrer M, et al: 2002; 28:426 – 431 ble-blind clinical trial. JAMA 1991; 265:
Semirecumbent position protects from pul- 90. Boyce JM, Pittet D: Healthcare Infection 2704 –2710
monary aspiration but not completely from Control Practices Advisory Committee. 102. Rodriguez-Roldan JM, Altuna-Cuesta A,
gastroesophageal reflux in mechanically HICPAC/SHEA/APIC/IDSA Hand Hygiene Lopez A, et al: Prevention of nosocomial
ventilated patients. Am J Respir Crit Care Task Force. Guideline for Hand Hygiene in lung infection in ventilated patients: Use of
Med 1995; 152:1387–1390 Health-Care Settings. Recommendations of an antimicrobial pharyngeal nonabsorbable
77. Torres A, Serra-Batlles J, Ros E, et al: Pul- the Healthcare Infection Control Practices paste. Crit Care Med 1990; 18:1239 –1242
monary aspiration of gastric contents in Advisory Committee and the HIPAC/SHEA/ 103. DeRiso AJII, Ladowski JS, Dillon TA, et al:
patients receiving mechanical ventilation: APIC/IDSA Hand Hygiene Task Force. Am J Chlorhexidine gluconate 0.12% oral rinse
The effect of body position. Ann Intern Med Infect Control 2002; 30:S1–S46 reduces the incidence of total nosocomial
1992; 116:540 –543 91. Girou E, Loyeau S, Legrand P, et al: Efficacy respiratory infection and nonprophylactic
78. Drakulovic MB, Torres A, Bauer TT, et al: of handrubbing with alcohol based solution systemic antibiotic use in patients undergo-
Supine body position as a risk factor for versus standard handwashing with antisep- ing heart surgery. Chest 1996; 109:
nosocomial pneumonia in mechanically tic soap: Randomised clinical trial. BMJ 1556 –1561
ventilated patients: A randomised trial. Lan- 2002; 325:362 104. Bonten MJ, Weinstein RA: Infection control
cet 1999; 354:1851– 8158 92. Pittet D, Hugonnet S, Harbarth S, et al: in intensive care units and prevention of
79. Torres A, El-Ebiary M, Soler N, et al: Stom- Effectiveness of a hospital-wide programme ventilator-associated pneumonia. Semin
ach as a source of colonization of the respira- to improve compliance with hand hygiene. Respir Infect 2000; 15:327–335
tory tract during mechanical ventilation: Lancet 2000; 356:1307–1312 105. Garcia S, Roque J, Ruza F, et al: Infection
Association with ventilator-associated pneu- 93. Ephgrave KS, Kleiman-Wexler R, Pfaller M, and associated risk factors in the immediate
monia. Eur Respir J 1996; 9:1729–1735 et al: Effects of sucralfate vs antacids on postoperative period of pediatric liver trans-
80. McClave SA, DeMeo MT, DeLegge MH, et al: gastric pathogens: Results of a double-blind plantation: A study of 176 transplants. Clin
North American Summit on Aspiration in clinical trial. Arch Surg 1998; 133:251–257 Transplant 1998; 12:190 –197
the Critically Ill Patient: consensus state- 94. Stoutenbeek CP, van Saene HK: Nonantibi- 106. D’Amico R, Pifferi S, Leonetti C, et al: Ef-
ment. JPEN 2002; 26:S80 –S85 otic measures in the prevention of ventila- fectiveness of antibiotic prophylaxis in crit-
81. Heyland DK, Drover JW, Dhaliwal R, et al: tor-associated pneumonia. Semin Respir ically ill adult patients: Systematic review of
Optimizing the benefits and minimizing the Infect 1997; 12:294 –299 randomised controlled trials. BMJ 1998;
risks of enteral nutrition in the critically ill: 95. Bonten MJM, Gaillard CA, van der Geest S, 316:1275–1285
Role of small bowel feeding. JPEN 2002; et al: The role of intragastric acidity and 107. Nathens AB, Marshall JC: Selective decon-
26:S51–S55 stress ulcer prophylaxis on colonization and tamination of the digestive tract in surgical
82. Ibrahim EH, Mehringer L, Prentice D, et al: infection in mechanically ventilated pa- patients: A systematic review of the evi-
Early versus late enteral feeding of mechan- tients. A stratified, randomized, double dence. Arch Surg 1999; 134:170 –176
ically ventilated patients: Results of a clini- blind study of sucralfate versus antacids. 108. de Jonge E, Schultz MJ, Spanjaard L, et al:
cal trial. JPEN 2002; 26:174 –181 Am J Respir Crit Care Med 1995; 152: Effects of selective decontamination of di-
83. Costerton W, Veeh R, Shirtliff M, et al: The 1825–1834 gestive tract on mortality and acquisition of
application of biofilm science to the study 96. Cook D, Guyatt G, Marshall J, et al: A com- resistant bacteria in intensive care: A ran-
and control of chronic bacterial infections. parison of sucralfate and ranitidine for the domized controlled trial. Lancet 2003; 362:
J Clin Invest 2003; 112:1466 –1477 prevention of upper gastrointestinal bleed- 1011–1016
84. Fuqua WC, Greenberg EP: Listening in on ing in patients requiring mechanical venti- 109. Kollef MH: Selective digestive decontami-
bacteria: Acyl-homoserine lactone signal- lation. N Engl J Med 1998; 338:791–797 nation should not be routinely employed.
ling. Nat Rev Mol Cell Biol 2002; 3:685– 695 97. Messori A, Trippoli S, Vaiani M, et al: Bleed- Chest 2003; 123:464s– 468s
85. Olson ME, Harmon BG, Kollef MH: Silver- ing and pneumonia in intensive care pa- 110. Hoth JJ, Franklin GA, Stassen NA, et al:
coated endotracheal tubes associated with tients given ranitidine and sucralfate for Prophylactic antibiotics adversely affect
reduced bacterial burden in the lungs of prevention of stress ulcer: Meta-analysis of nosocomial pneumonia in trauma patients.
mechanically ventilated dogs. Chest 2002; randomised controlled trials. BMJ 2000; J Trauma Injury Infect Crit Care 2003; 55:
121:863– 870 321:1–7 249 –254
86. Jones DS, McGovern JG, Woolfson AD, et al: 98. Bonten MJM, Bergmans DCJJ, Ambergen 111. Sirvent JM, Torres A, El-Ebiary M, et al:
Physicochemical characterization of hexeti- AW, et al: Risk factors for pneumonia, and Protective effect of intravenously adminis-
dine-impregnated endotracheal tube poly- colonization of respiratory tract and stom- tered cefuroxime against nosocomial pneu-
(vinyl chloride) and resistance to adherence ach in mechanically ventilated ICU patients. monia in patients with structural coma.

1404 Crit Care Med 2004 Vol. 32, No. 6


Am J Respir Crit Care Med 1997; 155: 121. Dennesen PJ, van der Ven AJ, Kessels AG, et 130. Tang R, Chen HH, Wang YL: Risk factors for
1729 –1734 al: Resolution of infectious parameters after surgical site infection after elective resec-
112. Rahal JJ, Urban C, Horn D, et al: Class antimicrobial therapy in patients with ven- tion of the colon and rectum: A single-
restriction of cephalosporin use to control tilator-associated pneumonia. Am J Respir center prospective study of 2,809 consecu-
total cephalosporin resistance in nosoco- Crit Care Med 2001; 163:1371–1375 tive patients. Ann Surg 2001; 234:181–199
mial Klebsiella. JAMA 1998; 280:1233–1237 122. Chastre J, Wolff M, Fagon JY, et al: Com- 131. Shorr AF, Duh M-S, Kelly KM, et al: Red
S113. Kollef MH, Vlasnik JSL, Sharpless L, et al: parison of 8 vs 15 days of antibiotic therapy blood cell transfusion and ventilator-
Scheduled change of antibiotic classes: A for ventilator-associated pneumonia in associated pneumonia. A potential link?
strategy to decrease the incidence of VAP. adults. JAMA 2003; 290:2588 –2598 Crit Care Med, In Press
Am J Respir Crit Care Med 1997; 156: 123. Micek ST, Ward S, Fraser VJ, et al: A random- 132. Cook D, Ricard JD, Reeve B, et al: Ventilator
1040 –1048 ized controlled trial of an antibiotic discon- circuit and secretion management strate-
114. Kollef MH, Ward S, Sherman G, et al: Inad- tinuation policy for clinically suspected ven- gies: A Franco-Canadian survey. Crit Care
equate treatment of nosocomial infections tilator-associated pneumonia. Chest, In Press Med 2000; 28:3547–3554
is associated with certain empiric antibiotic 124. Klugman KP, Madhi SA, Huebner RE, et al: 133. Rello J, Lorente C, Bodi M, et al: Why phy-
choices. Crit Care Med 2000; 28:3456 –3464 A trial of a 9-valent pneumococcal conju- sicians do not follow evidence-based guide-
115. Gruson D, Hilbert G, Vargas F, et al: Rota- gate vaccine in children with and those lines for preventing ventilator-associated
tion and restricted use of antibiotics in a without HIV infection. N Engl J Med 2003; pneumonia? A survey based on the opinions
medical intensive care unit. Am J Respir 349:1341–1348
of an international panel of intensivists.
Crit Care Med 2000; 162:837– 843 125. Eskola J, Kilpi T, Palmu A, et al: Finnish
Chest 2002; 122:656 – 661
116. Gruson D, Hilbert G, Vargas F, et al: Strat- Otitis Media Study Group. Efficacy of a
134. Ricart M, Lorente C, Diaz E, et al: Nursing
egy of antibiotic rotation: long-term effect pneumococcal conjugate vaccine against
adherence with evidence-based guidelines
on incidence and susceptibilities of Gram- acute otitis media. N Engl J Med 2001;
for preventing ventilator-associated pneu-
negative bacilli responsible for ventilator- 344:403– 409
monia. Crit Care Med 2003; 31:2693–2696
associated pneumonia. Crit Care Med 2003; 126. Nichol KL, Nordin J, Mullooly J, et al: In-
135. Cook DJ, Meade MO, Hand LE, et al: Toward
31:1908 –1914 fluenza vaccination and reduction in hospi-
understanding evidence uptake: Semire-
117. Raymond DP, Pelletier SJ, Crabtree TD, et talizations for cardiac disease and stroke
al: Sawyer RG. Impact of a rotating empiric among the elderly. N Engl J Med 2003; cumbency for pneumonia prevention. Crit
antibiotic schedule on infectious mortality 348:1322–1332 Care Med 2002; 30:1472–1477
in an intensive care unit. Crit Care Med 127. Shinefield H, Black S, Fattom A, et al: Use of 136. Helman DL, Sherner JH, Fitzpatrick TM, et
2001; 29:1101–1108 a Staphylococcus aureus conjugate vaccine al: Effect of standardized orders and pro-
118. Burke JP: Antibiotic resistance—squeezing in patients receiving hemodialysis. N Engl vider education on head-of-bed positioning
the balloon? JAMA 1998; 280:1270 –1271 J Med 2002; 346:491– 496 in mechanically ventilated patients. Crit
119. Singh N, Rogers P, Atwood CW, et al: Short 128. Vamvakas EC: Transfusion-associated can- Care Med 2003; 31:2285–2290
course empiric antibiotic therapy for pul- cer recurrence and postoperative infection: 137. Babcock HM, Zack JE, Garrison T, et al: An
monary infiltrates in the intensive care Meta-analysis of randomized, controlled educational intervention to reduce ventila-
unit: A proposed solution for indiscriminate clinical trials. Transfusion 1996; 36: tor-associated pneumonia in an integrated
antibiotic prescription. Am J Respir Crit 175–186 health system: a comparison of effects.
Care Med 2000; 162:505–511 129. Taylor RW, Manganaro L, O’Brien J: Impact Chest, In Press
120. Ibrahim EH, Ward S, Sherman G, et al: of allogenic packed red blood cell transfu- 138. Kollef MH: The importance of appropriate
Experience with a clinical guideline for the sion on nosocomial infection rates in the initial antibiotic therapy for hospital-
treatment of ventilator-associated pneumo- critically ill patient. Crit Care Med 2002; acquired infections. Am J Med 2003; 115:
nia. Crit Care Med 2001; 29:1109 –1115 30:2249 –2254 582–584

Crit Care Med 2004 Vol. 32, No. 6 1405