Journal of Infection and Public Health 13 (2020) 552–557

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Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

The incidence of ventilator-associated pneumonia (VAP) in a

tertiary-care center: Comparison between pre- and post-VAP
prevention bundle
Sara Osman a,b , Yousef M. Al Talhi b,c,∗ , Mona AlDabbagh a,b,c , Mohamed Baksh a,b,c ,
Mohamed Osman a,b , Maha Azzam a,b,c
a
Department of Pediatrics, King Abdulaziz Medical City, P.O. Box 65362, Jeddah 21556, Saudi Arabia
b
King Abdullah International Medical Research Centre, Jeddah, Saudi Arabia
c
King Saud bin Abdulaziz University for Health Sciences, P.O. Box 65362, Jeddah 21556, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Ventilator-associated pneumonia (VAP) is a nosocomial infection that develops 48 h after
Received 22 February 2019 the initiation of mechanical ventilatory support. Current evidence-based guidelines demonstrate that
Received in revised form 28 July 2019 VAP prevention is feasible through the implementation of certain VAP prevention bundle of interven-
Accepted 24 September 2019
tions simultaneously. We aimed in this study to investigate the effect of VAP prevention pre- and post-
implementation.
Keywords:
Methods: This is a single-center, cohort study that took place at the Pediatric Intensive Care Unit (PICU) of
Ventilator-associated pneumonia
King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia from January 2015 to March 2018 and assessed
VAP
VAP Bundle
the rate of VAP before and after implementation of the bundle.
PICU Results: The study included 141 children, 95 were included from the pre-bundle group and 36 from the
bundle group. VAP developed in 35% of the pre-bundle group compared to 31% of the bundle group
(p = 0.651) with incidence rates equaled to 18 and 12 per 1000 ventilator days, respectively.
Conclusion: This study found that VAP bundle did not significantly reduce VAP rate in the PICU. Further
large prospective multi-center studies with longer intervention duration are indicated to investigate the
benefits of using VAP prevention bundle.
© 2019 The Authors. Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for
Health Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Introduction with pooled cumulative incidence of 22.8% among mechanically

Ventilator-associated pneumonia (VAP) is a nosocomial infec-
tion that is not present at the time of intubation of patients
requiring ventilation and develops more than 48 h after the ini-
tiation of mechanical ventilatory support [1]. The prevalence of
VAP is not known precisely because of the variability in diagnostic
criteria; nevertheless, a surveillance study included 76 Paediatric
Intensive Care Units (PICUs) from 2010 to 2015 done by Rosen-
thal et al. showed that VAP occurred in 812 patients out of 29,197
(2.7%) [2]. VAP is considered the most frequent infection in PICUs
∗ Corresponding author at: King Abdullah International Medical Research Centre,
Jeddah, Saudi Arabia.
E-mail addresses: Attlhy009@ksau-hs.edu.sa, attlhyyo@ngha.med.sa
(Y.M. Al Talhi).
ventilated patients worldwide [3,4].
VAP has remained a significant nidus of morbidity and mortality
in PICU and is associated with increased length of stay, mechani-
cal ventilator days, and increased healthcare costs [5,6]. Currently,
evidence-based guidelines demonstrate that prevention of VAP
is feasible through the implementation of certain interventions
together and at the same time. This strategy is known as “a VAP
bundle” [1,7,8]. The implementation of VAP bundle to reduce the
incidence of VAP has become the focus of multiple international
organizations such as the Institute of Health-care Improvement
(IHI), the Joint Commission on Accreditation of Health-care Organi-
zation (JCAHO), the Intensive Care Society, Critical Care Nurse, and
American Thoracic Society [7,9–12].
The goal of this study was to apply a developed bundle for VAP
prevention as a process for quality improvement in the PICU of King
Abdulaziz medical city (KAMC)-Jeddah, Kingdom of Saudi Arabia
(KSA) aiming to decrease VAP events over a period of one year.

https://doi.org/10.1016/j.jiph.2019.09.015
1876-0341/© 2019 The Authors. Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 S. Osman et al. / Journal of Infection and Public Health 13 (2020) 552–557 553

Table 1
Ventilator-associated pneumonia (VAP) prevention bundle’s components which were developed after reviewing the medical literature with corresponding references.

VAP bundle components The references

Elevating Bed’s Head 30◦ –45◦ , reviewed every shift by the nurse in charge, to avoid [6,17]
aspiration of oropharynx secretions
Providing mouth hygiene through chlorhexidine 2% oral kits 4 times per day to reduce [12,17–20]
Bundle components as
oropharynx colonization
whole
Keeping ventilator circuits clean and dry through endotracheal tube (ETT) aspiration [12,17,21]
techniques standardized per international guidelines and manufacturer
recommendations to reduce device contamination; this includes suction around the
ETT before chanting or re-taping.
Hand washing before and after touching the patients [12,17]
Using cuffed ETT to avoid aspiration of oropharynx secretions [17]
Sedation holiday for deeply sedated patients every morning [6,17,18,22]
Using anti-reflex prophylaxis [12,23]

The bundle was applied through a process of quality improvement
using close monitoring and monthly auditing as a tool of staff stim-
ulation and compliance.
Methodology
This is a single-centre, cohort study that took place at the PICU
of KAMC-Jeddah from January 2015 up to March 2018. The PICU is
composed of 9 beds and 5 High Dependency Units. The admissions
average per year is around 550 patients, from various age groups
with different diagnoses. About 28% of admitted patients require
mechanical ventilation; 45% of those requires ventilation more than
48 h. The study included comparison between two study periods,
the first was pre-bundle implementation, from January 2015 to
February 2017, and the second was post-bundle implementation,
from March 2017 to March 2018. Fig. 1 unveils the study design
thoroughly.
The included subjects were all ventilated patients ageing from
one to 168 months (14 years) old who were admitted to the PICU
requiring ventilation more than 48 h.
VAP was identified as the presence of a new pneumonia in a
mechanically ventilated patient who was ventilated for more than
48 h. VAP surveillance was done for every patient on mechanical
ventilation for more than 48 h who had two or more serial chest
imaging revealing new or progressive and persistent infiltrates that
were evaluated for diagnosis of VAP. High Positive End-Expiratory
Pressure (PEEP) included all values >6 cmH2 O.
Since there are no gold-standard criteria for VAP diagnosis, VAP
was diagnosed based on a modified combination of both Centre
of Disease Control and Prevention (CDC) 2013 (sensitivity = 37%,
Specificity = 100%) and Johanson criteria (sensitivity = 69%, Speci-
ficity = 75%) [5,13–17]. A subject would be diagnosed with VAP
if: chest X-ray showed new infiltrates and at least 2 of the fol-
lowing criteria were present: (1) Fever more than 38 ◦ C; (2)
Abnormal White Blood Cells (WBCs) count; whether Leukocytosis
(>12,000/␮L) or leucopenia (/<2000/␮L) [13]; (3) Change in-the-
nature of respiratory secretions (color, amount, or nature; any
secretion that is not minimal, whitish, and loose); 4) Increased
C-reactive protein (CRP); an inflammatory marker (>3 mg/L); (5)
Positive blood or respiratory culture (6) Change in ventilator set-
ting; this included the Fractioned Inspired Oxygen (FiO2 ) (>50%),
Mean Airway Pressure (MAP) (>14 cmH2 O), and high Positive End-
Expiratory pressure(PEEP): values >6 cmH2 O.
The data was collected by the members of the PICU team; it
included PICU physicians, nurses and respiratory therapists who
were responsible for collecting the number of mechanical ventila-
tion days, admission days, and the percentage of compliance with
VAP bundle components during the period of the bundle applica-
tion.
The VAP prevention bundle followed in this study was a com-
bination of evidence-based bundles from the medical literature.
Table 1 illustrates the VAP Bundle developed for this study with
corresponding references. The bundle was approved prior to appli-
cation by PICU head section, PICU nurse manager, hospital nurse
educator, infection control department, and hospital administra-
tion.
Once the items of the VAP bundle were ready to be applied,
interventions were planned to fully orient PICU staff and to incor-
porate the bundle into daily practice; PICU staff received 8 weeks
of education prior to bundle application. Actions undertaken were
as follows: announcing the start of the VAP prevention program
and the main components of the VAP bundle via e-mail and for-
mally presenting the program by the PICU Director or the nurse
in-charge in all shifts; it included information about the develop-
ment of the VAP bundle, their specific items. The study materials
included lecturers, power-point presentations, short quizzes, and
educational posters. All academic activities had been supervised
and agreed by the nursing educational department and PICU head
section and nurse.
VAP bundle compliance was monitored by an assigned team of
3 members: a nurse, a physician, and a respiratory therapist. The
team tasks were; to do weekly and monthly audit and meeting
with or without PICU head nurse, making sure that the elements of
VAP bundle have been applied and reinforcing components of the
bundle that were difficult to implement, and to verify that the ele-
ments of the bundle have been objectively applied; for example,
looking at the degree of head elevation and observing for mouth
hygiene, cuffed tubes and sedation discontinuation. VAP bundle
flow-sheet was also implemented on the hospital documentation
system as part of routine patient nursing note documentation. Peri-
odical analysis of the adherence to the bundle was done every 3
months.
Regarding statistical analysis, descriptive statistics including
mean, standard deviation (SD), median, range, interquartile, or
proportions were used depending on the characteristics and dis-
tribution of the variables. The incidence rate of VAP was calculated
as discrete number per 1000 Mechanical Ventilator Day. Quanti-
tative variables to develop VAP were compared using unpaired
Student-T, Mann–Whitney tests or Independent Sample Median
Test. Qualitative variables were compared using chi-square ( 2 )
test or Fisher-Exact test as appropriate. A p-value (p) less than
0.05 was considered statistically significant. Statistical analysis was
done with Statistical Package of Social Sciences (SPSS) version 25.0.
This study was approved by the Institutional Review Board (IRB).
All patients’ data were anonymized and kept in the secured office
of the principal investigator.
Results
The study included 141 children aged 1–144 months, 95 were
included from the pre-bundle group and 36 from the post-bundle
554 S. Osman et al. / Journal of Infection and Public Health 13 (2020) 552–557

Fig. 1. Study design explained in details.

Table 2
Descriptive statistics comparing pre-bundle group to bundle group.

Variables Pre-bundle bundle p-Value

n = 95 n = 36

Median age in months (IQR) 12 (6) 15 (17) 0.733a

Male gender (%) 53 (56) 16 (44) 0.246b
Underlying medical disease category (%)
• Metabolic/neurological 10 (11) 4 (11)
• Respiratory 40 (42) 15 (42)
• Oncology 11 (2) 6 (17)
0.954b
• Immunodeficiencyd 7 (7) 2 (6)
• Cardiac 9 (10) 4 (11)
• Others 18 (19) 5 (14)

Ventilation mode (%)

• Endotracheal tube 86 (90.5) 33 (92)
0.571b
• Tracheostomy tube 9 (9.5) 3 (8)

Positive blood culture results (%) 14 (15) 4 (11) 0.901b

Positive respiratory culture results (%) 45 (47) 15 (42) 0.267b
High secretions (%) 33 (35) 19 (53) 0.060b
High fraction of inspired oxygen (%) 54 (57) 18 (50) 0.482b
High end expiratory positive airway pressure (%) 45 (47) 14 (39) 0.384b
High mean air-way pressure (%) 39 (41) 17 (47) 0.524b
High white blood cells (%) 48 (51) 19 (53) 0.818b
High C-reactive protein-CRP (%) 44 (46) 15 (42) 0.926b
Fever presence (%) 51 (54) 15 (42) 0.219b
Antibiotics usage (%) 57 (60) 23 (64) 0.421b
New infiltrates on chest X-ray (%) 59 (62) 15 (50) 0.209b

Development of VAP (%)

• Early 11 (11.58) 5 (13.89) 0.706
• Late 22 (23.16) 6 (16.67)

Overall development of ventilator associated pneumonia (VAP) (%) 33 (34.74) 11 (30.50) 0.651b
Median VAP ventilator days (IQR) 14 (12) 10 (9) 0.757a
Death due to VAP (%) 6 (6) 1(3) 0.7648c
VAP rate per 1000 ventilator days 18 12 0.127
a
Mann–Whitney test with 95% confidence interval.
b
Using chi-square test with 95% confidence interval.
c
Using Spearman’s rho test with 95% confidence interval.
d
Immunodeficiency was defined as patients with primary (inherited) immunodeficiencies or were on intense steroid dose (>2 mg/kg/day) for more than one week.

group. Among all ventilated subjects beyond 48 h, VAP occurred in Table 3

Compliance rate to bundle application per items.
35% of the pre-bundle group compared to 31% in the post-bundle
group (p = 0.651). The calculated VAP incidence rate equalled to 18 Bundle components Range of compliance rate
and 12 per 1000 ventilator days, respectively (p = 0.127). Table 2 Oral chlorohexidine usage 60–80%
illustrates the demographic characteristics of both pre and post- Hand washing 80%
bundle groups. The ventilation mode in both groups was mostly Head positioning 40–70%
endotracheal tube, 95% and 92% respectively. Antibiotics usage in Changing ventilator circuit 70–90%
Anti-reflux usage 60–80%
both groups was above 60%. The compliance to the VAP bundle was
Sedation holiday 20–40%
60% in the first 6 months and 80% in the latter 6. Table 3 details the Using cuffed tubes 30–60%
 S. Osman et al. / Journal of Infection and Public Health 13 (2020) 552–557 555

Table 4
Comparison between patients who developed ventilator-associated pneumonia (VAP) with those who did not in the pre-bundle group.

Variables No VAP n = 62 Developed VAP n = 33 p-Value

Median age in months (IQR) 13.5 (10) 7 (30) 0.089a

Male gender (%) 31 (50) 22 (67) 0.119b
Underlying medical disease category (%)
• Metabolic/neurological 5 (8) 5 (15)
• Respiratory 31 (50) 9 (27)
• Oncology 7 (11) 4 (12)
0.223b
• Immunodeficiencyc 3 (5) 4 (12)
• Cardiac 4 (6) 5 (15)
• Others 12 (19) 6 (18)
Ventilation mode (%)
• Endotracheal tube 55 (89) 31 (94)
0.407b
• Tracheostomy tube 7 (11) 2 (6)
High secretions (%) 28 (45) 5 (15) 0.003b
High fraction of inspired oxygen (%) 25 (40) 29 (88) 0.000b
High positive airway pressure (%) 19 (31) 26 (79) 0.000b
High mean air-way pressure (%) 14 (23) 25 (76) 0.000b
High white blood cells (%) 26 (42) 22 (67) 0.022b
High C-reactive protein (CRP) 20 (32) 24 (73) 0.000b
Fever presence (%) 25 (40) 26 (79) 0.000b
Antibiotics usage (%) 37 (60) 20 (61) 0.930b
New infiltrates on chest X-ray (%) 26 (42) 33 (100) 0.000b

Bold variables differed significantly between the two groups (VAP vs non-VAP) in both pre-bundle and post-bundle groups.
a
Using Mann–Whitney test with 95% confidence interval.
b
Using chi-square test with 95% confidence interval.
c
Immunodeficiency was defined as patients with primary (inherited) immunodeficiencies or were on intense steroid dose (>2 mg/kg/day) for more than one week.

Table 5
Comparison between patients who developed ventilator-associated pneumonia (VAP) with those who did not in the post-bundle group.

Variables No VAP n = 25 Developed VAP n = 11 p-Value

Median age in months (IQR) 12 (15) 17 (30) 0.359a

Male Sex (%) 9 (36) 7 (64) 0.124b
Underlying medical disease category (%)
• Metabolic/neurological 2 (8) 2 (18)
• Respiratory 11 (44) 4 (36)
• Oncology 4 (16) 2 (18)
0.747b
• Immunodeficiencyc 2 (8) 0
• Cardiac 2 (8) 2 (18)
• Others 4 (16) 1 (9)
Ventilation mode (%)
• Endotracheal tube 23 (92) 10 (91)
0.913b
• Tracheostomy tube 2 (8) 1 (9)
High secretions (%) 14 (56) 5 (45) 0.559b
High fraction of inspired oxygen (%) 9 (36) 9 (82) 0.11b
High positive airway pressure (%) 6 (24) 8 (73) 0.006b
High mean air-way pressure (%) 8 (32) 9 (82) 0.006b
High white blood cells (%) 11 (44) 8 (73) 0.112b
High C-reactive protein (CRP) 10 (40) 7 (64) 0.192b
Fever presence (%) 8 (32) 7 (64) 0.080b
Antibiotic usage (%) 14 (56) 9 (82) 0.137b
New infiltrates on chest X-ray (%) 7 (28) 11 (100) 0.000b

Bold variables differed significantly between the two groups (VAP vs non-VAP) in both pre-bundle and post-bundle groups.
a
Using Mann–Whitney test with 95% confidence interval.
b
Using chi-square test with 95% confidence interval.
c
Immunodeficiency was defined as patients with primary (inherited) immunodeficiencies or were on intense steroid dose (>2 mg/kg/day) for more than one week.

Table 6
Comparison between patients who developed ventilator-associated pneumonia (VAP) to those who did not in regard to the compliance to VAP bundle items.

Variables (bundle items) Development of VAP among the post bundle group p-Value*

No Yes
n = 25 (100%) n = 11 (100%)

Oral chlorohexidine usage (%) 15 (60) 8 (73) 0.464

Hand washing (%) 20 (80) 9 (82) 0.899
Head positioning (%) 11 (44) 4 (36) 0.669
Changing ventilator circuit (%) 20 (80) 10 (91) 0.418
Anti-reflux usage (%) 13 (52) 8 (73) 0.245
Sedation holiday (%) 6 (24) 2 (18) 0.699
Using cuffed tubes (%) 12 (48) 6 (55) 0.717
*
Using chi-square test with 95% confidence interval.
556 S. Osman et al. / Journal of Infection and Public Health 13 (2020) 552–557

Table 7 Literature of examining bundle effectiveness in PICU settings

Comparison between patients who developed ventilator-associated pneumonia
is limited. Bigham et al. caught sight of VAP prevention bundle
(VAP) among the pre-bundle group to those in the bundle group in terms of the
respiratory culture isolates.a effectiveness as VAP incidence rate significantly reduced from 5.6
to 0.3 VAP per 1000 Mechanical Ventilator Day (p < 0.0001) after
Respiratory isolatesb Development of VAP Respiratory isolatesb
bundle application [18]. Similarly, De Cristofano et al. found out
(n = 44)
Pre-bundle Post-bundle
that the rate of VAP has significantly decrease from 13.2% to 4.5%
n = 33 (100%) n = 11 (100%) with an incidence density equaled to 6.34 and 2.38 VAP per 1000
Mechanical Ventilator Day, respectively (p = 0.0047) [19]. On an
Pseudomonas 12d (36) 3c (27)
aeruginosa international, multi-PICUs participation level, Rosenthal et al. also
Klebsiella pneumoniae 4e (12) 4 (36) found that application of VAP prevention bundle has decrease VAP
Stenotrophomonas 5 (15) 1 (9) rate from 4.8% to 2.6% with incidence intensities being 11.7 and
maltophilia
8.1 VAP per 1000 Mechanical Ventilator Day (p = 0.0286) [20]. On
Acinetobacter baumanii 4c (12) 1 (9)
Enterobacter cloacae 3c (9) 1c (9) the contrary, yet similar to our study, Pena-Lopez et al. revealed an
Escherichia coli 2 (6) 1 (9) insignificant difference of VAP rate pre- (4.14 per 1000 Mechani-
Staphylococcus aureus 3f (9) – cal Ventilator Day) and post- (2.68 and 1.05 per 1000 Mechanical
Haemophilus influenzae 2 (6) – Ventilator Day) VAP prevention bundle (p = 0.088) [21].
Streptococcus 2 (6) –
Examining VAP prevention bundle was of a greater extent
pneumoniae
Moraxella catarrhalis 1 (3) – among neonates and adults. For example, Azab et al. brought off
Serratia marcescens 1 (3) – that VAP rate in the neonatal intensive care unit (NICU) significantly
Un-identified Gram -ve 1(3) – reduced from 68% with 36 VAP per per 1000 Mechanical Ventilator
Bacilli
Day to 38% with 23 VAP per 1000 Mechanical Ventilator Day after
a
No statistical significance was found by using Fisher-exact test with 95% confi- Bundle application (p = 0.0006). In addition, among adults, Lerma
dence interval where applicable. et al. brought the light to an impressively significant reduction of
b
Many of the respiratory specimens had more than one isolate at a time.
c VAP rate from 2.4% (n = 539) to 1.9% (n = 3186); p = <0.0001 with 7
One isolate was carbapenem resistant.
d
5 isolates were carbapenem resistant. VAP per 1000 Mechanical Ventilator Day to the latter [22].
e
Tow isolates were carbapenem resistant. Similarly, to this study, Amanati et al. concluded that age,
f
Two isolates were Methicillin-resistant Staphylococcus aureus. sex and antibiotics usage was not significantly associated to the
over-all rates of compliance to the bundle elements from the PICU development of VAP, however, compromised immune status is
team. (p = 0.014) [3]. A meta-analysis study also showed that the latter
Table 4 shows the comparison between patients who devel- variables were not significant for VAP development; other risk fac-
oped VAP with those who did not in the pre-bundle group. The tors to develop VAP, of which were not gone through in this study,
VAP group had a significantly higher rate of positive respiratory have been examined, too [23]. An apt usage of antibiotics should
cultures, high positive airway pressure, high mean airway pres- also be considered for the opposite can aggregate the risk for multi-
sure, high Oxygen requirements, high white blood count (WBC) drug resistance organism and mortality [24].
and high C-reactive protein (CRP). VAP subjects were also signifi- It is worth to mention that many countries adopted different
cantly more likely to have fever and new infiltrates on chest X-ray. approaches for VAP prevention; one of which is the International
Having increased secretions was, however, more documented in Nosocomial Infection Control Consortium (INICC), which includes
the non-VAP subjects. multidimensional approaches constituting the application of 6
Table 5, on the other hand, demonstrates the same compari- components for VAP prevention; these include: bundle application
son in the post-bundle group. On the contrary to the pre-bundle for infection prevention, education, outcome surveillance, pro-
group, subjects with VAP in the post-bundle group had only signif- cess surveillance, VAP rate feedback, and performance feedback
icantly higher rate of positive respiratory cultures, high positive [25]. Rosthenal et al. demonstrated in a multicenter study that
airway pressure, high mean airway pressure, as well as having included NICUs in 10 developing countries that the implementa-
new infiltrates on chest X-ray. There was no significant differ- tion of the (INICC) multidimensional infection prevention program
ence in the rate of fever, increased WBC or CRP. The age was not was associated with significant reduction in VAP rate (Relative risk
normally distributed in the three tables (p-value < 0.0001 using of 0.67; p = 0.001) [26]. Another approach was the “Zero-VAP” bun-
Kolmogorov–Smirnov Test); thus, the median and range were dle, which was initiated by the Spanish Societies of Intensive Care
reported. Medicine and of Intensive Care Nurses. This includes guidelines for
Further comparison was done between patients who developed prevention of VAP using surveillance database on VAP episodes,
VAP and those who did not regarding the compliance to VAP Bun- which is classified into three main sets of methods; a functional
dle elements (Table 6). This comparison showed no statistically set, a mechanical set, and a pharmacological set [27].
significant difference between the two groups indicating that the The compliance to VAP prevention bundle appeared as a “game
compliance rate among those patients were similar (whether low changer” in the literature. For example, the adherence to the bundle
or high). and its effectiveness were examined by Samra et al., and they con-
Respiratory culture isolates among patients who developed VAP cluded that the incidence of VAP decreased significantly between
in the pre- and post- bundle groups are summarized in Table 7. “non-bundle” and “bundle” groups (18.5% vs 9%, p < 0.05) with min-
Infection caused by Carbapenem-resistant gram-negative organ- imal adherence rate of 94% per month. The authors highlighted that
isms was reported in 25% (11/44) of all VAP cases; this rate dropped “zero-VAP” has been attained in many months, and it required con-
from 26% in the pre-bundle group to 18% in the post-bundle group siderable awareness to the bundle items and a very firm adherence
yet was not statistically significant (p = 1.0). by labelling the bundle as a local policy [28]. Similarly, by plot-
ting both bundle compliance and VAP rate per month, Caserta et al.
Discussion found out that the rate of VAP reached zero in many months once
the compliance exceeded 95% [29]. Those findings suggest that the
In this study, after 1 year of implementation, no statistically sig- bundle could tackle the VAP rate, and its impact is not “Delphic”;
nificant change was found in VAP rate between pre- and post- VAP however, it could be clouded by the compliance rate. Therefore, we
prevention bundle. believe that with higher compliance rate (up to 95%) would help
 S. Osman et al. / Journal of Infection and Public Health 13 (2020) 552–557
achieving a zero VAP rate, even if for few months, modelling what
happened with Caserta et al. and Samra et al. [28,29].
Limitations
This research has focused only on the importance of VAP rate
reduction after the bundle was applied. Other ventilator-associated
infections, such as Ventilator-Associated Tracheitis (VAT), were not
investigated. This study was hindered by the single-centre involve-
ment, the bereft sample size, and the limited duration of bundle
application; the low compliance to bundle played a major role too.
Conclusion
This study’s findings question the efficacy of VAP prevention
bundle application to decrease VAP rate and call for more prospec-
tive, multi-centre studies examining the bundle’s effectiveness. The
various diagnostic criteria of VAP and whether the VAP prevention
bundle was applied with high compliance or not might compete
in spot of the different reported incidence rates; the heterogenous
components of the applied bundle could play a role too.
Funding
No funding sources.
Competing interests
None declared.
Ethical approval
Not required.
Acknowledgements
We would like to thank the PICU nurses and team, especially
nurse Basma Falata, nurse Mary Ruth, Dr. Abdullah Alzahrani, Dr.
Amir Shehzad, Dr. Abdulrahman Aboutaleb, Mr. Riyadh Alshehri
and Mr. Abdulsalam Alzahrani, for their cooperation during the
study conduction. Special thanks to Mr. Waleed W. Khayyat for his
valuable input and review of the manuscript prior to publication.
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