Ventilator-associated Pneumonia in the Intensive Care Unit of the Institute of Oncology Ljubljana in 2021 and the Role of Nurses in its Prevention

Sabina Medjedovic; Tomaž Jurca; Milena Kerin  Povšič

doi:10.3889/oamjms.2023.11470

Authors

Sabina Medjedovic Institute of Oncology, Ljubljana, Slovenia
Tomaž Jurca Institute of Oncology, Ljubljana, Slovenia
Milena Kerin Povšič Institute of Oncology, Ljubljana, Slovenia

DOI:

https://doi.org/10.3889/oamjms.2023.11470

Keywords:

ventilator-associated pneumonia, incidence, quality, education, nurses

Abstract

BACKGROUND: Ventilator-associated pneumonia (VAP) is the most common infection in critically ill patients and has the highest mortality. It prolongs ventilation time and length of stay, increases antibiotic consumption, increases the likelihood of death, increases the cost of treatment, and is difficult to diagnose.

AIM: At the intensive care unit (ICU) of the Institute of Oncology, Ljubljana, we prospectively monitor risk factors for VAP and its incidence. It is a mixed surgical/internal ICU.

METHODS: A centers of disease control and prevention VAP diagnosis criteria and strategies to prevent VAP were used. Registered nurses recorded risk factors in all intubated patients in all three shifts, and the diagnosis protocol was completed by the physician in case of antibiotic administration in suspected VAP.

RESULTS: The expected incidence of VAP is around 18/1,000 ventilated days. In 2021, 67 patients were mechanically ventilated in our ICU (patients who completed ventilation in that year). The total time spent on ventilation was 17,143 h or 714.3 days. As the criteria for ventilator-assisted pneumonia (VAP) is >48 h of ventilation, we excluded 19 patients who had been ventilated for 48 h or less. Among 48 patients who were ventilated for > 48 h, the total ventilation was 16,765 h or 698.5 days. We recorded 8 VAP in 714 days, which is 1 VAP per 89 days of ventilation or 11.2/1,000 ventilation days. Healthcare staff, especially registered nurses, play a major role in VAP prevention, providing care every day, all days of the week. Most prevention interventions and strategies are part of routine nursing care. Lack of knowledge about infection prevention and appropriate nursing care among nurses can become a barrier to adherence to evidence-based guidelines for the prevention of VAP.

CONCLUSION: This study will help nurses to learn about VAP and its prevention in detail so that they can apply the knowledge in clinical practice. Understanding the pathophysiology of VAP, its risk factors and the nursing care bundle is essential for appropriate prevention and treatment of VAP. Specific protocols, strategies, and active control should be available in each ICU regarding the care bundle.

Downloads

Download data is not yet available.

Metrics

Metrics Loading ...

Plum Analytics Artifact Widget Block

References

World Health Organization. Noncommunicable Diseases Progress Monitor. Geneva: World Health Organization; 2022.

Chadani O, Deepa W, Bimala P, Qinghua Z. Ventilatorassociated pneumonia and role of nurses in its prevention. J Nepal Med Assoc. 2017;56(208):461-8. PMid:29453481.

Battaglia CC, Hale K. Hospital-acquired infections in critically ill patients with cancer. J Intensive Care Med. 2019;34(7):523-36. https://doi.org/10.1177/0885066618788019 PMid:30012057 DOI: https://doi.org/10.1177/0885066618788019

Wu D, Wu C, Zhang S, Zhong Y. Risk factors of ventilator- associated pneumonia in critically III patients. Front Pharmacol. 2019;10:482. https://doi.org/10.3389/fphar.2019.00482 PMid:31143118 DOI: https://doi.org/10.3389/fphar.2019.00482

Kalanuria AA, Ziai W, Mirski M. Ventilator-associated pneumonia in the ICU. Crit Care. 2014;18(2):208. https://doi.org/10.1186/ cc13775 PMid:25029020 DOI: https://doi.org/10.1186/cc13775

Zupanc TL, Pokorn M. Bolnišnična pljučnica. In: Tomaţič J, Strle F, editors. Infekcijske Bolezni. Ljubljana: Zdruţenje za Infektologijo, Slovensko Zdravniško Društvo; 2014. p. 272-80.

Fernando SM, Tran A, Cheng W, Klompas M, Kyeremanteng K, Mehta S, et al. Diagnosis of ventilator-associated pneumonia in critically ill adult patients-a systematic review and meta-analysis. Intensive Care Med. 2020;46(6):1170-9. https://doi.org/10.1007/s00134-020-06036-z PMid:32306086 DOI: https://doi.org/10.1007/s00134-020-06036-z

McEnery T, Martin-Loeches I. Predicting ventilator-associated pneumonia. Ann Transl Med. 2020;8(11):670. https://doi.org/10.21037/atm.2020.03.173 PMid:32617290 DOI: https://doi.org/10.21037/atm.2020.03.173

Álvarez-Lerma F, García MS. The multimodal approach for ventilator-associated pneumonia prevention-requirements for nationwide implementation. Ann Transl Med. 2018;6(21):420. https://doi.org/10.21037/atm.2018.08.40 PMid:30581828 DOI: https://doi.org/10.21037/atm.2018.08.40

Kim EJ, Kwak YG, Kwak SH, Ko SH, Kim JH, Kim ES, et al.

Korean national healthcare-associated infections surveillance system, intensive care unit module report: Summary of data from July 2018 to June 2019. Korean J Healthc Assoc Infect Control Prev. 2020;25(2):115-27. DOI: https://doi.org/10.14192/kjicp.2020.25.2.115

Institute for Healthcare Improvement. Getting started kit: Prevent ventilator-associated pneumonia: How-to guide. Crit Care Nurs Q. 2006;29(2):157-73. https://doi.org/10.1097/00002727-200604000-00010 PMid:16641653 DOI: https://doi.org/10.1097/00002727-200604000-00010

Rello J, Lode H, Cornaglia G, Masterton R, Masterton R, Rello J, et al. A European care bundle for prevention of ventilator- associated pneumonia. Intensive Care Med. 2010;36:773-80. DOI: https://doi.org/10.1007/s00134-010-1841-5

Jahansefat L, Vardanjani MM, Bigdelian H, Massoumi G, Khalili A, Mardani D. Exploration of knowledge of, adherence to, attitude and barriers toward evidence-based guidelines (EBGs) for prevention of ventilator-associated pneumonia (VAP) in healthcare workers of pediatric cardiac intensive care units (PCICUs): A quali-quantitative survey. Int J Med Res Health Sci. 2016;5(9):67-73.

Agodi A, Barchitta M, Quattrocchi A, Spera E, Gallo G, Auxilia F, et al. Preventable proportion of intubation-associated pneumonia: Role of adherence to a care bundle. PLoS One. 2017;12(9):e0181170. https://doi.org/10.1371/journal.pone.0181170 PMid:28877171 DOI: https://doi.org/10.1371/journal.pone.0181170

Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R, et al. Nurse staffing and education and hospital mortality in nine European countries: A retrospective observationalstudy. Lancet. 2014;383(9931):1824-30. https://doi.org/10.1016/S0140-6736(13)62631-8 PMid:24581683 DOI: https://doi.org/10.1016/S0140-6736(13)62631-8

Papazian L, Klompas M, Luyt CL. Ventilator-associated pneumonia in adults: A narrative review. Intensive Care Med. 2020;46(5):888-906. https://doi.org/10.1007/s00134-020-05980-0 PMid:32157357 DOI: https://doi.org/10.1007/s00134-020-05980-0

Stoclin A, Rotolo F, Hicheri Y, Mons M, Chachaty E, Gachot B, et al. Ventilator-associated pneumonia and bloodstream infections in intensive care unit cancer patients: A retrospective 12-year study on 3388 prospectively monitored patients. Support Care Cancer. 2020;28(1):193-200. https://doi.org/10.1007/s00520-019-04800-6 DOI: https://doi.org/10.1007/s00520-019-04800-6

Oliveira J, Zagalo C, Cavaco-Silva P. Prevention of ventilator- associated pneumonia. Rev Port Pneumol. 2014;20(3):152-61. https://doi.org/10.1016/j.rppneu.2014.01.002 PMid:24674617 DOI: https://doi.org/10.1016/j.rppneu.2014.01.002

Evans CR, Sharpe JP, Swanson JM, Wood GC, Fabian TC, Croce MA, et al. Keeping it simple: impact of a restrictive antibiotic policy for ventilator-associated pneumonia in trauma patients on incidence and sensitivities of causative pathogens. Surg Infect (Larchmt). 2018;19(7):672-8. https://doi.org/10.1089/sur.2018.087 PMid:30204541 DOI: https://doi.org/10.1089/sur.2018.087

Mahapatra A, Patro S, Sarangi G, Das P, Mohapatra D, Paty B, et al. Bacteriological profile of ventilator-associated pneumonia in a tertiary care hospital. Indian J Pathol Microbiol. 2018;61(3):375-9. https://doi.org/10.4103/ijpm.ijpm_487_16 PMid:30004058 DOI: https://doi.org/10.4103/IJPM.IJPM_487_16

Lewis RH, Sharpe JP, Swanson JM, Fabian TC, Croce MA, Magnotti LJ. Reinventing the wheel: Impact of prolonged antibiotic exposure on multidrug-resistant ventilator-associated pneumonia in trauma patients. J Trauma Acute Care Surg. 2018;85(2):256-62. https://doi.org/10.1097/TA.0000000000001936 PMid:29664891 DOI: https://doi.org/10.1097/TA.0000000000001936

Osti C, Wosti D, Pandey B, Zhao Q. Ventilator-associated pneumonia and role of nurses in its prevention. J Nepal Med Assoc. 2017;56(208):461-8. PMid:29453481. DOI: https://doi.org/10.31729/jnma.3270

Ding C, Zhang Y, Yang Z, Wang J, Jin A, Wang W, et al. Incidence, temporal trend and factors associated with ventilator- associated pneumonia in mainland China: A systematic review and meta-analysis. BMC Infect Dis. 2017;17(1):468. https://doi.org/10.1186/s12879-017-2566-2567 PMid:28676087 DOI: https://doi.org/10.1186/s12879-017-2566-7

Ferrer R, Artigas A. Clinical review: Non-antibiotic strategies for preventing ventilator-associated pneumonia. Critic Care.

;6(1):45-51. https://doi.org/10.1186/cc1452 PMid:11940265 DOI: https://doi.org/10.1186/cc1452

De Rosa FG, Craven DE. Ventilator-associated pneumonia: Current management strategies. Infect Med. 2003;20(5):248-59.

Augustyn B. Ventilator-associated pneumonia risk factors and prevention. Crit Care Nurse. 2007;27(4):32-9. PMid:17671243 DOI: https://doi.org/10.4037/ccn2007.27.4.32

Walaszek M, Kosiarska A, Gniadek A, Kołpa M, Wolak Z, Dobroś W, et al. The risk factors for hospital-acquired pneumonia in the intensive care unit. Przegl Epidemiol. 2016;70(1):107-10. PMid:27344468

Thatrimontrichai A, Rujeerapaiboon N, Janjindamai W, Dissaneevate S, Maneenil G, Kritsaneepaiboon S, et al. Outcomes and risk factors of ventilator-associated pneumonia in neonates. World J Pediatr. 2017;13:328-34. https://doi. org/10.1007/s12519-017-0010-10 DOI: https://doi.org/10.1007/s12519-017-0010-0

Liu Y, Di Y, Fu S. Risk factors for ventilator-associated pneumonia among patients undergoing major oncological surgery for head and neck cancer. Front Med. 2017;11(2):239-46. https://doi.org/10.1007/s11684-017-0509-8 PMid:28493197 DOI: https://doi.org/10.1007/s11684-017-0509-8

Papakrivou E, Makris D, Manoulakas E, Karvouniaris M, Zakynthinos E. Intra-abdominal hypertension is a risk factor for increased VAP incidence: A prospective cohort study in the ICU of a tertiary hospital. J Intensive Care Med. 2018a;35(7):700-7. https://doi.org/10.1177/0885066618779369 PMid:29902954 DOI: https://doi.org/10.1177/0885066618779369

Guillamet CV, Kollef MH. Is zero ventilatorassociated pneumonia achievable? practical approaches to ventilator-associated pneumonia prevention. Clin Chest Med. 2018;39(4):809-22. https://doi.org/10.1016/j.ccm.2018.08.004 PMid:30390751 DOI: https://doi.org/10.1016/j.ccm.2018.08.004

Bouglé A, Tuffet S, Federici L, Leone M, Monsel A, Dessalle T, et al. Comparison of 8 versus 15 days of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia in adults: A randomized, controlled, open-label trial. Intensive Care Med. 2022;48(7):841-9. https://doi.org/10.1007/s00134-022-06690-5 PMid:35552788 DOI: https://doi.org/10.1007/s00134-022-06690-5

Mirtalaei N, Farazi A, Monfared ME, Jokar A. Efficacy of antibiotic prophylaxis against ventilator-associated pneumonia. J Hosp Infect.

;101(3):272-5. https://doi.org/10.1016/j.jhin.2018.08.017 PMid:30179656 DOI: https://doi.org/10.1016/j.jhin.2018.08.017

Mahmoodpoor A, Hamishehkar H, Asghari R, Abri R, Shadvar K, Sanaie S. Effect of a probiotic preparation on ventilator-associated pneumonia in critically ill patients admitted to the intensive care unit: A prospective double-blind randomized controlled trial. Nutr Clin Pract. 2019;34(1):156-62. https://doi.org/10.1002/ncp.10191 PMid:30088841 DOI: https://doi.org/10.1002/ncp.10191

Centers for Disease Control and Prevention. Summary for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during the COVID-19 Response. United States: Centers for Disease Control and Prevention; 2019. Available from: https://www.cdc.gov [Last accessed on 2020 Jan 15].

Bardwell J, Brimmer S, Davis W. Implementing the ABCDE bundle, critical-care pain observation tool, and richmond agitation-sedation scale to reduce ventilation time. AACN Adv Crit Care. 2020;31(1):16-21. https://doi.org/10.4037/aacnacc2020451 PMid:32168511 DOI: https://doi.org/10.4037/aacnacc2020451

Institute for Clinical Systems Improvement. Health Care Protocol: Prevention of Ventilator-Associated Pneumonia. 5th ed. Bloomington, MN, USA: Institute for Clinical Systems Improvement; 2011. p. 1-30.

Safarabadi M, Ghaznavi-Rad E, Pakniyat A, Rezaie K, Jadidi A. Comparing the effect of echinacea and chlorhexidine mouthwash on the microbial flora of intubated patients admitted to the intensive care unit. Iran J Nurs Midwifery Res. 2017;22(6):481-5. https://doi.org/10.4103/ijnmr.IJNMR_92_16 PMid:29184589 DOI: https://doi.org/10.4103/ijnmr.IJNMR_92_16

Dikmen Y, Filiz NY. A recent view and evidence-based approach to oral care of intensive care patient. Int J Caring Sci. 2016;9(2):1177-85.

Meidani M, Khorvash F, Abbasi S, Cheshmavar M, Tavakoli H. Oropharyngeal irrigation to prevent ventilator- associated-pneumonia: Comparing potassium permangenate with chlorhexidine. Int J Prev Med. 2018;9:93. https://doi.org/10.4103/ijpvm.IJPVM_370_17 PMid:30450176 DOI: https://doi.org/10.4103/ijpvm.IJPVM_370_17

Munro CL. Oral health: Something to smile about! Am J Crit Care. 2014;23(4):282-8. https://doi.org/10.4037/ajcc2014440 PMid:24986168 DOI: https://doi.org/10.4037/ajcc2014440

Povšič Kerin M. Pneumonia in the intensive care unit. In: Petrovec M, editor. 5th Banič Days-Healthcare Associated Infections. Proceedings of the meeting, Šempeter pri Novi Gorici, November 2013;52(6):42-8.

Zand F, Zahed L, Mansouri P, Dehghanrad F, Bahrani M, Ghorbani M. The effects of oral rinse with 0.2% and 2% chlorhexidine on oropharyngeal colonization and ventilator associated pneumonia in adults’ intensive care units. J Crit Care. 2017;40:318-22. https://doi.org/10.1016/j.jcrc.2017.02.029 PMid:28320561 DOI: https://doi.org/10.1016/j.jcrc.2017.02.029

O’Malley CA. Device cleaning and infection control in aerosol therapy. Respir Care. 2015;60(6):917-30. https://doi.org/10.4187/respcare.03513 PMid:26070583 DOI: https://doi.org/10.4187/respcare.03513

Keyt H, Faverio P, Restrepo MI. Prevention of ventilator- associated pneumonia in the intensive care unit: A review of the clinically relevant recent advancements. Indian J Med Res. 2014;139(6):814-21. PMid:25109715