Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Philip Marcus, M.D., M.P.H.[2]
Overview
Among the factors contributing to contracting HAP are mechanical ventilation (ventilator-associated pneumonia), old age, decreased filtration of inspired air, intrinsic respiratory, neurologic, or other disease states that result in respiratory tract obstruction, trauma, (abdominal) surgery, medications, diminished lung volumes, or decreased clearance of secretions may diminish the defenses of the lung. Also poor hand-washing and inadequate disinfection of respiratory devicescauses cross-infection and is an important factor.
Overview
Major points for risk factors of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia (DONOT EDIT) [1]
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Major Points and Recommendations for Modifiable Risk Factors
General prophylaxis
- Effective infection control measures: staff education, compliance with alcohol-based hand disinfection, and isolation to reduce cross-infection with MDR pathogens should be used routinely (Level I).
- Surveillance of ICU infections, to identify and quantify endemic and new MDR pathogens, and preparation of timely data for infection control and to guide appropriate, antimicrobial therapy in patients with suspected HAP or other nosocomial infections, are recommended (Level II).
Intubation and mechanical ventilation
- Intubation and reintubation should be avoided, if possible, as it increases the risk of VAP (Level I).
- Noninvasive ventilation should be used whenever possible in selected patients with respiratory failure (Level I).
- Orotracheal intubation and orogastric tubes are preferred over nasotracheal intubation and nasogastric tubes to prevent nosocomial sinusitis and to reduce the risk of VAP, although direct causality has not been proved (Level II).
- Continuous aspiration of subglottic secretions can reduce the risk of early-onset VAP, and should be used, if available (Level I)
- The endotracheal tube cuff pressure should be maintained at greater than 20 cm H2O to prevent leakage of bacterial pathogens around the cuff into the lower respiratory tract.
- Contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or in-line medication nebulizers (Level II).
- Passive humidifiers or heat–moisture exchangers decrease ventilator circuit colonization, but have not consistently reduced the incidence of VAP, and thus they cannot be regarded as a pneumonia prevention tool (Level I).
- Reduced duration of intubation and mechanical ventilation may prevent VAP and can be achieved by protocols to improve the use of sedation and to accelerate weaning (Level II).
- Maintaining adequate staffing levels in the ICU can reduce length of stay, improve infection control practices, and reduce duration of mechanical ventilation (Level II).
Aspiration, body position, and enteral feeding
- Patients should be kept in the semirecumbent position (30–45°) rather than supine to prevent aspiration, especially when receiving enteral feeding (Level I).
- Enteral nutrition is preferred over parenteral nutrition to reduce the risk of complications related to central intravenous catheters and to prevent reflux villous atrophy of the intestinal mucosa that may increase the risk of bacterial translocation (Level I).
Modulation of colonization: oral antiseptics and antibiotics
- Routine prophylaxis of HAP with oral antibiotics (selective decontamination of the digestive tract or SDD), with or without systemic antibiotics, reduces the incidence of ICU-acquired VAP, has helped contain outbreaks of MDR bacteria (Level I), but is not recommended for routine use, especially in patients who may be colonized with MDR pathogens (Level II).
- Prior administration of systemic antibiotics has reduced the risk of nosocomial pneumonia in some patient groups, but if a history of prior administration is present at the time of onset of infection, there should be increased suspicion of infection with MDR pathogens (Level II).
- Prophylactic administration of systemic antibiotics for 24 hours at the time of emergent intubation has been demonstrated to prevent ICU-acquired HAP in patients with closed head injury in one study, but its routine use is not recommended until more data become available (Level I).
- Modulation of oropharyngeal colonization by the use of oral chlorhexidine has prevented ICU-acquired HAP in selected patient populations such as those undergoing coronary bypass grafting, but its routine use is not recommended until more data become available (Level I).
- Use daily interruption or lightening of sedation to avoid constant heavy sedation and try to avoid paralytic agents, both of which can depress cough and thereby increase the risk of HAP (Level II).
- Comparative data from randomized trials suggest a trend toward reduced VAP with sucralfate, but there is a slightly higher rate of clinically significant gastric bleeding, compared with H2 antagonists. If needed, stress bleeding prophylaxis with either H2 antagonists or sucralfate is acceptable (Level I).
- Transfusion of red blood cell and other allogeneic blood products should follow a restricted transfusion trigger policy; leukocyte-depleted red blood cell transfusions can help to reduce HAP in selected patient populations (Level I).
- Intensive insulin therapy is recommended to maintain serum glucose levels between 80 and 110 mg/dl in ICU patients to reduce nosocomial blood stream infections, duration of mechanical ventilation, ICU stay, morbidity, and mortality (Level I).
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References
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References
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