Journal of Critical Care (2008) 23, 5–10

The impact of ventilator-associated pneumonia on the

Canadian health care systemB
John G. Muscedere MD a , Claudio M. Martin MD b , Daren K. Heyland MD, MSc a,⁎
a
Queens University, Kingston, Canada K7L 2V7
b
University of Western Ontario, Ontario, Canada N6A 4G5

Keywords:
Abstract
Ventilator-associated
Introduction: Ventilator-associated pneumonia (VAP) is a cause of morbidity and mortality in critically
pneumonia;
ill patients. It is associated with increased health care costs and duration of mechanical ventilation.
Nosocomial infections;
Using published data and information from public health care providers, we sought to determine the
Canadian health care
impact of VAP on the Canadian health care system.
system
Methods: Ventilator-associated pneumonia incidence, attributable mortality, and intensive care unit
(ICU) utilization/resource data were obtained through Canadian published and institutional data. Ontario
case cost methodology was used for the cost of a critical care bed which is CAN$2396 per day,
excluding treatment costs. Antibiotic acquisition costs for Ontario were used. Physician reimbursement
rates were obtained from the provincial ministries of health. Ventilator-associated pneumonia data, ICU
resource data, and costs were combined to determine the impact of VAP.
Results: For the Canadian health care system; ICU utilization is 217 episodes per 100 000 population
and 1150 days of mechanical ventilation per 100 000. The incidence of VAP is 10.6 cases per 1000
ventilator days (95% CI, 5.1-16.1). Ventilator-associated pneumonia increases ICU length of stay
4.3 days (95% CI, 1.5-7.0 days) per episode. The attributable mortality of VAP is 5.8% (95% CI, −2.4 to
14). The number of cases of VAP is estimated to be approximately 4000 cases per year (95% CI, 1900-
6100). This results in 230 deaths per year with the lower and upper confidence intervals ranging from
0 to 580. Ventilator-associated pneumonia accounts for approximately 17 000 ICU days per year or
around 2% of all ICU days in Canada. The cost to the health care system is CAN$46 million (possible
range, $10 million to 82 million) per year.
Conclusion: The impact of VAP on the Canadian health care system is considerable. Eradication of this
preventable nosocomial infection would save lives and conserve scarce health care resources.
© 2008 Elsevier Inc. All rights reserved.

☆
Conflicts of interest: J Muscedere and D Heyland have received
unrestricted research grants for studies in VAP unrelated to the present
manuscript from Astra-Zeneca and Bayer Pharmaceuticals.
⁎ Corresponding author. Tel.: +1 613 549 6666#3339; fax: +1 613
548 1351.
E-mail address: dkh2@queensu.ca (D.K. Heyland).
1. Introduction
Nosocomial infections are an important cause of morbidity
and mortality in hospitalized patients and are associated with
increased health care costs [1]. Hospital acquired pneumonia
is the second most common nosocomial infection after urinary

0883-9441/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jcrc.2007.11.012
6 J.G. Muscedere et al.
tract infections but accounts for up to 60% of deaths associated
with nosocomial infection [2]. Hospitalized patients who
receive invasive mechanical ventilation in the ICU have the
highest risk of developing nosocomial pneumonia and this
infection is called ventilator-associated pneumonia (VAP). In
a recent review, the pooled cumulative incidence of VAP was
found to be 22.8% (95% confidence interval [CI], 18.8-26.9)
and conferred a 2-fold attributable risk of dying in the ICU
(odds ratio, 2.02; 95% CI, 1.16-3.56) to patients who
developed it. The costs attributable to VAP were US$10 019
per patient [3]. However, this review included reports from
different countries and health care systems in which the
incidence, costs, and attributable mortality may be all
markedly different. As a result, the applicability to any
individual country or region is limited or unknown.
From a health care perspective, it is important to know the
economic consequences from VAP on individual health care
systems such that resources commensurate with the problem
are committed to improving the outcomes of VAP. In
Canada, several initiatives are underway to address VAP but
the proportionality of the resources committed relative to
the economic burden of VAP is unclear as the costs of VAP to
the Canadian health care system are unknown [4,5].
Moreover, VAP is not a reportable disease, surveillance is
not carried out on a systematic basis, and a national database
for VAP does not exist. The aim of this study was to
determine the clinical and economic impact of VAP in
Canada. Specifically, we sought to determine the incidence
of VAP, the amount of additional ventilator/ICU days, and
deaths attributable to VAP in the context of the Canadian
health care system.
2. Methods
We conducted a literature search of Medline, EMBASE,
COCHRANE, and CINAHL databases to identify studies
that reported on the incidence, morbidity, mortality, and
health care costs of VAP in Canada. Databases of abstracts
(the web or websites of professional organization such as the
American Thoracic Society, Society of Critical Care
Medicine, Canadian Association of Medical Microbiology
and Infectious Diseases) [6-8] were searched and any
reported or presented abstracts were included if they reported
on Canadian VAP data. In addition, we obtained data on VAP
from Canadian institutions/organizations where it was
available. For VAP incidence, at least a year of data had to
be available for it to be included and the last year for which
VAP data were available was used.
Data on the incidence and duration of mechanical
ventilation in Canada were obtained by using the same
search strategy as for VAP. We used these data to determine
the number of ventilator days in Canada. The incidence of
VAP (in cases per 1000 ventilator days) was multiplied by
the number of ventilator days to estimate the national number
of cases of VAP per year. Based on the number of cases of
VAP, reported attributable mortality, and excess length of
stay from VAP, we obtained the total mortality and impact on
ICU utilization. The number of cases of VAP was also used
to determine the total possible health care costs associated
with VAP. In calculating the costs of VAP, the following
costs were considered: cost of an ICU bed, antibiotic costs,
and physician costs. In the absence of current Canadian data
on the cost of ICU care [9], we used Ontario case cost
methodology for the cost of a critical care bed ($2396 per
day) and compared it to reported costs from other health care
systems [10]. For pharmacy costs, we only used the costs of
antibiotics and for these, we used antibiotic acquisition costs
for Ontario. Antibiotic costs were modeled on treatment
duration of 10 days (IQR, 5-15) as found in a recent multi-
center Canadian trial [11]. Typical treatment regimens were
considered including empiric therapy for both methicillin-
resistant Staphylococcus aureus (MRSA) and Pseudomonas
species, and subsequent step-down therapy with one agent,
as in the vast majority Pseudomonas species are not isolated
and one agent is adequate. The regimens for the treatment
of VAP considered were vancomycin and ceftazidime for
3 days followed by levofloxacin for 7 days and vancomycin,
meropenem, and ciprofloxacin for 3 days followed by
ceftriaxone for 7 days. Costs for physician reimbursement
across Canada were obtained from provincial fee schedules
for daily ICU care. For most of the provinces, physician fees
are reduced at the 7- to 10-day point of the patients' ICU stay.
For the purposes of this analysis, it was assumed that
three quarters of ICU treatment days for VAP occur before
the 10-day point. Physician costs were available for 6 of the
10 provinces and were either not available for the rest or
physician reimbursement was on a procedural basis. The
average physician costs in the 6 provinces where it was
known were generalized to the rest of Canada. The
population of Canada of 32 623 490 was obtained from the
2006 Canada census [12]. All reported costs are in 2006
Canadian dollars.
2.1. Statistical analysis
The incidence of VAP was obtained by averaging the
reports that provided the incidence of VAP. Rates are
reported in cases per 1000 ventilator days. Means are
reported with CIs, unless the data were skewed and then
medians and interquartile ranges are reported. The upper and
lower values of the 95% CIs for the inputted variables were
used to obtain possible ranges for the estimates obtained.
3. Results
The literature search revealed 4 studies [13-16] that
reported on the incidence of VAP; two were in abstract form
only [15,16]. Of these studies, 3 reported on single centers
The impact of VAP on the Canadian health care system 7

Table 1 Incidence of VAP Table 3 Annual estimates of the impact of VAP

Source Population Incidence (cases/ Parameter Base case Range (95% CI)
1000 vent day) Incidence 10.6 cases/ 5.1-16.1 cases/
Cook et al, 1998 [13] Medical/surgical 14.8 1000 vent days 1000 vent days
Zuege et al, 2003 [15] Medical/surgical 19.6 VAP Cases 4000 1900-6100
Kingston General Medical/ 10.2 Excess ICU days a 17 000 days 3000-31 000 days
Hospital, 2004 [17] surgical/trauma (55 ICU beds) b (10-106 ICU beds) b
Baxter et al, 2005 [14] Medical/surgical 12.5 Excess deaths c 232 0-580
St Paul's Hospital, Medical/surgical 2 Excess cost (range, $46 million d $10 million-
2005 [18] $4950-17 950) $82 million
Calgary Health Region, Medical/surgical 10.3 a
Based on 4.3 ICU days (95% CI, 1.5-7.0 days) per case.
2005 [19] b
Based on an average occupancy of 80%, 1 ICU bed generates 292
Davis et al, 2005 [16] Medical/surgical 4.7 ICU days per year.
Average 10.6 (95% CI, c
Based on attributable mortality of 5.8% (95% CI, −2.4 to 14).
d
5.1-16.1) Based on cost of 1 450 per case.

days per year. With an incidence of VAP of 10.6 cases per

[14-16] and one was from a multicenter study [13]. 1000 ventilator days (95% CI, 5.1-16.1), the total number of
Institutional data on the incidence of VAP were available VAP cases per year in Canada is approximately 4000 (95%
from three sources [17-19]. The institutional data and the CI, 1900-6100).
single center reports included data on 7 ICUs with a total of In regard to ICU days, Needham et al [20] reported ICU
116 medical/surgical/trauma beds. The incidence of VAP in days were 2552 per 100 000 population, which translates into
these reports is tabulated in Table 1. The mean incidence was 832 000 ICU days per year in Canada. The only Canadian
calculated as 10.6 cases per 1000 ventilator days (95% CI, study that reported on increases in ICU length of stay and
5.1-16.1). attributable mortality from VAP was Heyland et al [22]. Each
Two studies [20,21] reported on intensive care utilization case of VAP was found to increase ICU length of stay by
in Canada but the study of Rapoport et al [21] was excluded 4.3 days (95% CI, 1.5-7.0 days) and attributable mortality
as it did not report on mechanical ventilation rates. Needham was reported as 5.8% (95% CI, −2.4 to 14). Based on this
et al [20] reported on the incidence of noncardiac surgery and the projected number of VAP cases in Canada (4000;
mechanical ventilation in adults from a physician billing 95% CI, 1900-6100), the approximate number of attributable
database in Ontario, Canada, from 1992 to 2000 [20]. The VAP ICU days is 17 000 days per year (95% CI, 3000-
data from the last year reported were used. The incidence of 31 000). This is 2% of all ICU days in Canada. With a
mechanical ventilation was 217 episodes per 100 000 mortality rate of 5.8%, the number of deaths attributable to
population with each episode of mechanical ventilation VAP in Canada per year is approximately 230 with the lower
being 5.3 days, which is equivalent to 1150 days of and upper CIs ranging from 0 to 580.
mechanical ventilation per 100 000 population. For the entire Antibiotic costs for a 10-day course of treatment for VAP
population of Canada, this translates into 375 000 ventilator ranged from $293 to $703. For a 15-day treatment course,
costs would increase by $120 to $170. Physician costs
Table 2 Per case costs of VAP ranged from $53 per day to $229 per day depending on the
Resource Basis Cost per day Total Range
day of treatment and the province. We determined that the
of total average for physician costs was $151 per day (95% CI, 119-
183), which yields a total of $650 per case of VAP (95% CI,
ICU Bed Ontario case $2396 per day $10 300 a $3800-
220-1080).
cost 16 800
Total costs (Table 2) for each case of VAP are $11 450 with
methodology b
Antibiotics 10 d of therapy $49.80 per day $498 $293- a range of $4950 to $17 950. Based on 4000 cases of VAP
(range) ($29.30-70.30) 703 per year, the total cost of VAP per year is approximately
Physician Provincial fees 51 (95% CI, $650 $220- $46 million per year with a range of $10 million to
costs across Canada 119-183) 1080 $82 million. By varying the underlying assumptions on
(95% incidence, costs, and mortality, the possible ranges for burden
CI) of illness are outlined in Table 3.
Total $11 450 $4950-
17 950
a
Totals are based on an increase in ICU stay of 4.3 days (95% CI, 4. Discussion
1.5-7.0 days) per case of VAP.
b
The amount that hospitals are reimbursed for the operation of an
Using Canadian data, we have attempted to quantify the
ICU bed per day by the province of Ontario.
impact of VAP on the Canadian health care system. As VAP
8 J.G. Muscedere et al.
is not a reportable nosocomial infection, this information is
not readily available and we used secondary sources for these
data. Using conservative assumptions, we determined that
VAP costs approximately $11 500 per case, is responsible
for approximately 230 deaths per year, and accounts for
approximately 17 000 additional ICU days per year. This
represents approximately 45 ICU beds (55 ICU beds at 80%
occupancy) or the equivalent of 3 to 4 ICUs completely
occupied for the whole year solely to treat patients with
VAP. To put this into context, it is estimated that there are
2600 ICU beds in Canada capable of mechanical ventilation
[23]; the number of beds occupied because of VAP is
approximately 2% of all ICU beds. Although 2% is not large
in absolute terms, it needs to be emphasized that VAP is
not present on ICU admission and that a significant
proportion of ICU resources are required for the treatment
of this ICU complication.
To arrive at a conservative estimate of the direct cost of
VAP, the only components considered were the ICU per
diem, antibiotic, and physician costs. The majority of the cost
of VAP was from the cost of an ICU bed and the prolongation
of ICU stay secondary to VAP. For the cost of an ICU bed,
we used the amount that hospitals are reimbursed for the
operation of an ICU bed per day by the province of Ontario, a
single provider health care system for approximately one
third of the Canadian population [10]. Although we could not
obtain costs from other provinces, they also act as single
provider systems for health care and it is unlikely that their
costs would be significantly different. In this method of
accounting for ICU costs, other costs such as additional
imaging studies, laboratory tests, equipment, and services of
healthcare professionals other than physicians are considered
to be included in the daily ICU bed cost. The advantage of
this is that from a societal perspective this is the actual cost
of funding the operation of an ICU bed and avoids the
difficulties inherent in conducting a detailed cost analysis
such as the variability in ICU bed cost depending on the day
of the ICU stay. Although detailed cost accounting was
not used for this study, previous data from a Canadian ICU
revealed a median cost of CAN$2600 per day which is
similar to the cost of an ICU bed that we used (CAN$2396
per day) and is similar to that reported in other jurisdictions
[3,9,24]. We used a prolongation of ICU stay of 4.3 days,
which is low when compared to reports from other
jurisdictions of 5.5 days to more than 11 days [25-27].
Thus, the main determinant of cost, which is the ICU stay,
is realistic, likely conservative, and consistent with other
reports in the literature.
For antibiotic costs, conservative assumptions were used
for the duration of treatment and it was assumed that therapy
would be tailored to less expensive antibiotics once culture
results were available. These costs would be much higher if
tailoring of antibiotic therapy did not occur or if multi-
resistant organisms or Pseudomonal species were isolated
requiring prolonged courses of broad-spectrum antibiotics
with their attendant costs. For example, a 2-week course of
meropenem and ciprofloxacin both administered intrave-
nously as would be the case for a Pseudomonal infection
would cost $3372 compared to the average cost of $649 used
in our analysis.
The impact of VAP has not been previously determined
for the Canadian health care system. However, our estimate
of cost is remarkably similar to a recently published
systematic review that used different methodology and
determined that the cost of each case of VAP was US$10 019
[3]. Previous reported estimates of the cost of VAP have
ranged from US$5365 (CAN$6278) to US$50 000 (CAN
$58 505) per case, with the variability attributable to the
methodology used [28-30].
The attributable mortality of VAP has been reported to be
between 0% and 40% and is related to the adequacy of initial
therapy and the population studied [31-35]. We used the
attributable mortality reported by Heyland et al [22] of 5.8%
as that was derived in a Canadian setting. If the range of
attributable mortality reported in the literature is applied to
the incidence of VAP, then it is possible that the excess
mortality from VAP in Canada ranges from 0 to 2000 deaths
per year. It should be emphasized that this attributable
mortality is in a relatively small population of critically ill
patients. In contrast, Clostridium difficile–associated diar-
rhea, another nosocomial infection that has received much
attention and affects the whole hospital population, or 5 to
10 times the number of ventilated critically ill patients, has
been reported to have a 1% associated mortality and
potentially causes 150 to 190 deaths per year [36,37].
From a public safety perspective, the number of deaths from
VAP is potentially higher than that from HIV/AIDS (100
deaths per 2003 calendar year) and in the range of the
number of fatalities from motor vehicle accidents per year
(2778 deaths per 2001 calendar year) [38,39].
The major strength of this study is that it examines the
impact of VAP across the Canadian health care system rather
than at an institutional level. To increase the robustness of
our conclusions and applicability to the Canadian context,
only Canadian data from multiple sources were used. In
addition, a system-wide analysis of the impact of VAP has
not been previously done.
A limitation of this study is the lack of direct data on the
Canadian incidence of VAP and rates of mechanical
ventilation. Ventilator-associated pneumonia incidence was
obtained from several sources including the literature and
self-reported VAP incidence at several institutions across
Canada. These included both academic and community
centers, and these data are comparable to data reported by the
National Nosocomial Infection Surveillance [40] in the
United States. As such, it is likely to be representative of true
VAP rates. In regard to mechanical ventilation data, there is
no direct measurement of days of mechanical ventilation
across Canada, but the incidence that we used was from a
Canadian database encompassing approximately one third of
the Canadian population and there is no reason to suspect
that this does not generalize across Canada. In addition, the
The impact of VAP on the Canadian health care system
incidence of 217 episodes per 100 000 population is
conservative in view of published reports of the rising
incidence of mechanical ventilation [41,42]. The main
component of the direct costs of VAP is the prolongation
of ICU stay. There was only one report on this issue in
Canadian patients, but it is also consistent with or lower
than other published reports [3,43,44].
It should be emphasized that the significant morbidity,
mortality, and cost of VAP demonstrated in these analyses
are only some of the direct costs of VAP and that there are
also other costs, both direct and indirect, that are beyond the
scope of these analyses. An example of a direct cost for
which there is no information is the possible increased
hospital length of stay in addition to ICU LOS. Examples of
other costs include, but are not limited to, other pharmaceu-
tical costs; increased antibiotic costs driven in part from
increasing microbial resistance caused partially by the
treatment of nosocomial infections, secondary infections,
and complications acquired during the increased ICU LOS;
and increased need for ICU beds and their attendant costs. In
addition, there is no information on societal costs such as
lost productivity and impact on the families of patients with
VAP. Although it is difficult to determine these indirect costs,
their effect on society may be greater than direct costs [45].
Owing to the lack of data on these costs, they are not
included and as such any calculation of burden of illness
from VAP is bound to be an artificially low estimate of its
true impact on patients, the healthcare system, and society.
However, it is clear that the impact of VAP on patients'
lives and the health care system is considerable in spite of the
limitations and conservative assumptions used in this
analysis. Ventilator-associated pneumonia is in part pre-
ventable [46], but the penetration on preventive strategies
into clinical practice is poor and the extent that it can be
reduced is uncertain [47,48]. Studies of educational efforts to
implement VAP prevention practices have been consistent in
demonstrating reduction of VAP rates in the 50% range and
there have been reports of VAP rates of 0 [49-53]. Although
studies of the implementation of all known effective VAP
prevention practices have not been completed thus far, this is
currently underway in a multicenter study across Canada and
should provide further evidence as to the degree that VAP
rates and its impact on the Canadian Health care system can
be reduced [54]. However, a conservative reduction in VAP
rates by 50%, which has been shown to be achievable, would
conservatively save approximately 120 lives and $25 million
per year.
Health care professionals and decision makers have not
marshaled the system-wide resources required to reduce the
impact of VAP. In addition, the initiatives underway are
poorly funded compared to the national cost of VAP. As an
example, VAP prevention in Canada is one of 6 initiatives
directed by Safer Health Care Now, a program of the
Canadian Patient Safety Institute, which has a yearly budget
of only $10 million for all patient safety initiatives in
Canada. As the incidence of mechanical ventilation rises
9
secondary to the aging demographics of our population
and our improving ability to support critically ill patients
[41,42], the impact of this health care–associated infection
will rise. A national surveillance system to track the
incidence of VAP would provide direct information on the
impact of VAP on the Canadian health care system and
provide evidence as to the utility of interventions imple-
mented to reduce its impact.
5. Conclusion
The impact of VAP on the Canadian health care system is
considerable. Further efforts at eradication of this potentially
preventable nosocomial infection would save lives and
preserve scarce health care resources.
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