The Prevention, Diagnosis, and Treatment of Ventilator-Associated Pneumonia

Problem Statement

Ventilator-Associated Pneumonia (VAP) is a dangerous illness affecting intubated patients in Critical Care units. According to a study by Efrati, Deutsch, Antonelli, Hockey, Rozenblum, and Gurman, VAP is common in critical care units with “a pooled relative risk of 9-27% and a mortality of 25-50%.” (Efrati et al, 2010 p. 162) VAP also contributes significantly to hospital admission costs. Despite many studies, VAP remains a hi-risk, costly, and poorly-understood illness.

Description of symptoms of the problem

The risks, mortality rate, and costs associated with VAP in critical care adults are due to three fundamental symptoms. First, though Efraiti et al divide the preventative measure into two categories, evidence-based practical guidelines (EBPG) and technical solutions, there is a variety of opinions among clinicians on how to use these tools to adequately prevent infection. (2010, p. 162) Additionally, as most patients who contract VAP are unconscious and therefore incommunicative and unable to report symptoms, it is particularly difficult for the illness to be diagnosed. Additionally, “Diagnostic testing is required whenever VAP is suspected because clinical findings alone are not specific” enough to identify the pathogen (Efrati, 2010, p. 162) Finally, according to Koeneg and Truwit, the administration of treatment for patients with VAP has been problematic because of the two shortcomings in diagnosis listed above. (2006, p. 644) Treatment of VAP is often delayed due to late diagnosis. Delays in pneumonia treatment with “appropriate antibiotic therapy has been associated with excess mortality,” raising rates up to 48%. (Koeneg and Truwit, 2006, p. 644)

Literature Search

(Keywords and resources omitted for preview. Available via download)

Description of modification of keywords to retrieve the best results along with keywords that yielded the most fruitful searches. I initially searched for “Ventilator-associated pneumonia,” but this search proved much too broad as the results included articles from as long as fifteen to twenty years ago on topics reaching from homeopathic treatments for VAP to VAP in pediatric units. I adjusted the publication date preference filter, and I searched for “ventilator-associated pneumonia” combined with an additional related topic, such as “mortality rates.” This returned more up to date and relevant results than the first search. I continued to search for sources in this way by combining the phrase “ventilator-associated pneumonia” with "pneumonia- review of literature" and additional topics of interest throughout the rest of my research and found some very informative articles.

Data Evaluation

Bouza, E., Granda, M. J., Hortal, J., Barrio, J. M., Cercanado, E., & Munoz, P. (2013, September). Pre-emptive broad-spectrum treatment for ventilator-associated pneumonia in high-risk patients. National Center for Biotechnology Information. doi: 10.1007/s00134-013-2997-6

Canton-Potsdam Hospital marks full year without any ventilator-related pneumonias NorthCountryNow. (2013, July 15). North Country Now. Retrieved August 4, 2013, from http://northcountrynow.com/news/canton-potsdam-hospital-marks-full-year-without-any-ventilator-related-pneumonias-090905

Centers for Disease Control and Prevention. (2012, May 17). Retrieved from http://www.cdc.gov/HAI/vap/vap.html

Efrati, S., Deutsch, I., Antonelli, M., Hockey, P. M., Rozenblum, R., & Gurman, G. M. (2010). Ventilator-associated pneumonia: Current status and future recommendations. Journal of Clinical Monitoring and Computing, 24(2), 161-168. doi: 10.1007/s10877-010-9228-2

John, S., Karlnoski, R., Manger, D., Koll, J., Munoz, G., Thompson, P., ... Camporesi, E. M. (2013). Impact of a Low-Pressure Polyurethane Adult Endotracheal Tube on the Incidence of Ventilator-Associated Pneumonia: A before and after Concurrence Study. ISRN Critical Care, 2013, 1-6. doi: 812964

Koenig, S. M., & Truwit, J. D. (2006). Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention. Clinical Microbiology Reviews, 19(4), 637-657. doi: 10.1128/CMR.00051-05

Restrepo, M., Anzueto, A., Arroliga, A., Afessa, B., Atkinson, M., Ho, N., ... Kollef, M. (2010). Economic Burden of Ventilator‐Associated Pneumonia Based on Total Resource Utilization. Infection Control and Hospital Epidemiology, 31(5), 509-515. doi: 10.1086/651669

Shibu, B., Susan, B., Nair, S., Ganesan, S., Bipin, R., & Sahagun, M. (2011). Implementation and compliance to ventilator associated pneumonia prevention bundle in a private health care facility in the United Arab Emirates. Journal of Critical Care, 26(5), E37. doi: 10.1016/j.jcrc.2011.05.033

Winters, B. D., & Berenholtz, S. M. (2013, March). Ventilator Associate Pneumonia: Brief Update Review. Making Health Care Safer II. Retrieved August 4, 2013, from http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html

Justification and determination that each source is appropriate using the elements of the CARS checklist. See chart in the appendix.

Annotated Bibliography

Bouza, E., Granda, M. J., Hortal, J., Barrio, J. M., Cercanado, E., & Munoz, P. (2013, September). Pre-emptive broad-spectrum treatment for ventilator-associated pneumonia n high-risk patients. National Center for Biotechnology Information. doi: 10.1007/s00134-013-2997-6

1. Describe the content (focus) of the source. This study identifies patients who are intubated while recovering from major heart surgery as being at high risk for VAP infection. During a study, 78 patients were divided into a control and an experimental group, the former receiving standard care and the latter being preemptively given a three-day course of linezolid and meropenem. (Bouza et al., 1013, p. 1550) 2. Describe the usefulness of the source. This source identifies and tests a possibility for VAP preventative care, and provides reason to think that the administration of broad-spectrum antibiotics to patients about to be intubated ought to become standard care. 3. Discuss any limitations that the source may have. The patients in the study presented were all recovering from major heart surgery. This is too narrow of a sample as patients being provided with mechanical ventilation for different reasons may respond differently due to VAP infection or antibiotics differences in immune system strength/weakness, or variations in medication. 4. Describe the audience that the source is intended for. This article is intended for researchers and clinicians. 5. Discuss the authors’ conclusions. The study shows that despite the administration of antibiotics, both groups were intubated for an average of six days; however, the source notes that “as mortality was higher in the control group, patients in the intervention group were able to be ventilated longer that broad-spectrum antibiotics may offset or delay VAP infection by 4.5 days. The study concludes that the preemptive administration of broad-spectrum antibiotics may offset or delay VAP infection in patients recovering from major heart surgery. Bouza et al., 2013, p. 1550) 6. Describe your reaction to the source. I think that this source gives an informed evaluation of an important VAP study. The source is credible as it was initially published in a peer-reviewed journal run by The European Society of Intensive Care Medicine. 

Canton-Potsdam Hospital marks full year without any ventilator-related pneumonias NorthCountryNow. (2013, July 15). North Country Now. Retrieved August 4, 2013, from http://northcountrynow.com/news/canton-potsdam-hospital-marks-full-year-without-any-ventilator-related-pneumonias-090905

Describe the content (focus) of the source. This is a newspaper article which is reporting the story of a hospital that has gone for one year without a single patient acquiring VAP infection. The article focuses on this hospitals success, interviews a clinical care director and infection prevention specialist, and details the causes and clinical/financial effects of VAP in ordinary language. This source also elaborates on some of the procedures this hospital adopted in order to stymie VAP infection. 2. Describe the usefulness of the source. Being a newspaper article, the language in this source is very general and non-specific. Additionally, this source does not provide much substantive information regarding the preventative procedures adopted in response to PAV. However, this article is useful in that it shows that it may be possible for critical care units to nullify PAV infection through the education and of staff and patient’s families in infection control. 3. Discuss any limitations that the source may have. This article was published in a newspaper rather than a peer-reviewed journal. Furthermore, this source contains no quantitative analyses of the infection rate decline as compared with the implementation of preventative practices. 4. Describe the audience that the source is intended for. This source was written with a general, non-specialized readership. 5. Discuss the authors’ conclusions. This article does is not reflective of any analyses, arguments, or studies. It does not offer a conclusion in the academic sense. 6. Describe your reaction to the source. I was disappointed that the author did not go into more detail about the procedures adopted by this critical care unit. Moreover, the article does not mention whether technological advancements or pharmaceutical treatments played a role in the hospital’s infection record or whether the elimination of VAP is a result solely of effective infection prevention such as administering vaccines, nurse education, and training. However, I was pleased with this source as it demonstrates that VAP infection is preventable and unnecessary.

Centers for Disease Control and Prevention. (2012, May 17). Retrieved from http://www.cdc.gov/HAI/vap/vap.html

Describe the content (focus) of the source. This is the ventilator-associated pneumonia section of the Centers for Disease Control website (CDC). The source’s focus is on providing basic information, answering frequently asked questions about, and informing family members, care-providers and clinicians of the dangers of and preventative measures for VAP. The source also contains a number of links to articles and websites regarding standard care for intubated patients with respect to VAP. 2. Describe the usefulness of the source. This source is useful because, as the articles, manuals, and webpages it links to are extremely general and out of date, it corroborates claims made by several of my other sources that state that many medical organizations, doctors, nurses, caregivers, and families members are undereducated with regard to VAP and its preventative practices. 3. Discuss any limitations that the source may have. In terms of the quality and quantity of information about VAP infection prevention, this source is extremely limited and inadequate. However, this fact makes this source useful example of the inadequate training of medical personnel and families members that are referenced in my other sources. 4. Describe the audience that the source is intended for. This source is intended for both general and professional readerships. 5. Discuss the authors’ conclusions. This is not an article, but a webpage that purports to convey the standard care given to prevent VAP infection and provide links to relevant journal articles, manuals, and other sources. It has does not list an author. 6. Describe your reaction to the source. I feel that this source will be useful not because of the information it contains, but because of the up to date, scholarly information that it does not contain. The CDC is the US’s national public health institute and, as such, should provide relevant, up to date, and accurate medical information to both medical practitioners and the public alike. Its failure to discharge this obligation with respect to VAP is good evidence of the claims of inadequate education and training in VAP infection standards in the medical field made by several of my other sources.

Efrati, S., Deutsch, I., Antonelli, M., Hockey, P. M., Rozenblum, R., & Gurman, G. M. (2010). Ventilator-associated pneumonia: Current status and future recommendations. Journal of Clinical Monitoring and Computing, 24(2), 161-168. doi: 10.1007/s10877-010-9228-2

Describe the content (focus) of the source. This article attempts to review and compile literature relevant to VAP infection and prevention in two parts. The first part summarizes current findings on VAP’s epidemiology and pathogenesis. The second part of the article explores both the evidence-based practical guidelines (EBPGs) and the technological developments that have been developed to prevent infection. 2. Describe the usefulness of the source. This source is useful in that it condenses a vast amount of up to date research about VAP infection and compiles it into one source. It thus represents a generalization of widely held practices and technological implementations. This sources also specifically details the steps in EBPGs that are germane to intubated patients and VAP prevention and explains how these standards serve to prevent infection. Additionally, this source describes the technological resources, such as subglottic drainage tubes, silver-coated endotracheal tubes, and ultra-thin sealing cuffs which may be used to prevent VAP infection. (Efrati et al., 2010, p.163-166 3. Discuss any limitations that the source may have. This source reviews and condenses information which is already known about VAP parthenogenesis and prevention. As such, it does not contribute to the advancement of knowledge about VAP infection. It will be useful to inform guidelines about clinical standards of care for intubated patients, but its findings will not likely contribute to future research. 4. Describe the audience that the source is intended for. This article is intended for clinicians. 5. Discuss the authors’ conclusions. The authors conclude that increased standards and practices in critical care units and technological developments are areas which should be focused on by practitioners in order to control and lessen the likelihood of VAP infection. 6. Describe your reaction to the source. I think that this source is a helpful and credible analysis of accepted, contemporary preventative measures and technologies. This means that it provides a standard to which research into VAP prevention through the implementation of practical guidelines and advancements in technology which are outside the standard can be compared and evaluated. 

John, S., Karlnoski, R., Manger, D., Koll, J., Munoz, G., Thompson, P., Camporesi, E. M. (2013). Impact of a Low-Pressure Polyurethane Adult Endotracheal Tube on the Incidence of Ventilator-Associated Pneumonia: A before and after Concurrence Study. ISRN Critical Care, 2013, 1-6. doi: 812964

1. Describe the content (focus) of the source. The study that this source provides tests operates on the idea that the build-up of subglottic secretions increases an intubated patient’s susceptibility to VAP infection. This source provides an analysis of the preventative effects of endotracheal tubes fitted with ultrathin, low-pressure, polyurethane cuffs “which reduces channel formation and fluid leakage from the subglottic area.” (John et al., 2013, p. 1) Ideally, the use of this technology will reduce the likelihood of infection by encouraging subglottic secretion drainage (SSD). 2. Describe the usefulness of the source. This is closely related to some of my other sources, particularly the article by Efrati et al., which suggest that the material compositions of endotracheal tubes can influence the likelihood of VAP patients. This means that the results of this study can be compared to the results of my other sources. 3. Discuss any limitations that the source may have. This study compares only two groups of patients: those intubated with low-pressure polyurethane endotracheal tubes which allow for SSD and those intubated with conventional tubes which do not allow for SSD. This means that the results of the study are more reflective of an endotracheal tube’s capacity for SDD rather than its composition. 4. Describe the audience that the source is intended for. This source is intended for clinicians and researchers. 5. Discuss the authors’ conclusions. The author concludes that endotracheal tubes outfitted with polyurethane cuffs and SSD systems may be used to deter early and late-onset VAP infection in intubated patients. 6. Describe your reaction to the source. I think that this source is informative and credible due to its localized study group, its thoroughly documented research, and the qualifications of its authors.

Koenig, S. M., & Truwit, J. D. (2006). Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention. Clinical Microbiology Reviews, 19(4), 637-657. doi: 10.1128/CMR.00051-05

1. Describe the content (focus) of the source. This paper outlines and analyzes what its authors consider to be the ideal practices with respect to VAP infection diagnosis, prevention, and treatment. It also explains why a low threshold for suspicion of VAP is needed when a patient’s clinical course deteriorates.” (Koenig and Truwit, 2006, p. 652) This paper also elaborates on the specifics of prevention guidelines for clinical care providers by focusing on several preventative measures, infection symptoms, diagnostic procedures for intubated patients and treatment options for patients who become infected with VAP. 2. Describe the usefulness of the source. This article is useful as it corroborates the findings of several of the studies reported in my other sources, specifically those by Shibo et al., and Bouza et al. Additionally, this source distinguishes the different pathogens associated with VAC infection and contributes an analysis of the financial impact of VAP infection on patients and hospital. Furthermore, this source includes a detail flow-chart and algorithm which specifies the steps for the diagnosis and treatment of VAP infection. (Koenig and Truwit, 2006, p. 647) 3. Discuss any limitations that the source may have. This paper is six years old which may mean that some of its statistics and recommendations are out of date. 4. Describe the audience that the source is intended for. This article is intended for practicing critical care clinicians. 5. Discuss the authors’ conclusions. The authors conclude that the rate of VAP infection, complications, and mortality in critical care patients can be greatly reduced through the implementation of the recommended treatment and prevention guidelines, technological resources, and diagnostic procedures. The authors also conclude that reduction can be established with minimal cost and effort from clinicians and critical care units and will be more cost-effective for hospitals overall. 6. Describe your reaction to the source. This article takes information from many other sources into consideration and forms its conclusion from empirical, fact-based evidence and accurate quantitative analysis. I think this makes it useful in establishing a base-line standard for VAP prevention, diagnosis, and treatment from which to which the guidelines outlined in my other sources can be compared.

Restrepo, M., Anzueto, A., Arroliga, A., Afessa, B., Atkinson, M., Ho, N., Kollef, M. (2010). Economic Burden of Ventilator‐Associated Pneumonia Based on Total Resource Utilization. Infection Control and Hospital Epidemiology, 31(5), 509-515. doi: 10.1086/651669

Describe the content (focus) of the source. This source details the cost of VAP infection in patients in terms of an institution’s healthcare finances and resources. Toward this end, the authors “performed a retrospective, matched cohort analysis of mechanically ventilated patients enrolled in the North American Silver-Coated Endotracheal Tube (NASCENT) study.” (Restrepo et al., 2010, P. 1) The article uses the findings of this study to analyze the effects of VAP infection in terms of length of hospital stay, cost of an infected patient’s aggregate treatment time, and draws on hospital services and resources. 2. Describe the usefulness of the source. This article is very useful in analyzing the effects of VAP on critical care providers because the study focuses on the institutional consequences of infection. 3. Discuss any limitations that the source may have. First, the NASCENT study, on which the findings of this source are based, was performed from 2002-2006, which means that the information utilized by the authors is slightly dated. Second, the only significant variable in the NASCENT study is the use of a silver-coated endotracheal tube for patient intubation. This means that the results reflect a disparity between patients who were outfitted with this device and those who were not. As such, other possible variations in treatment were not taken into substantial consideration. Therefore, this source is only relevant to the cost/benefit analysis of a particular technology. 4. Describe the audience that the source is intended for. This source is directed toward practicing clinicians and clinical care administrators. 5. Discuss the authors’ conclusions. The authors conclude that VAP infection increases hospital costs, length of stay, and the use of institutional resources. Similar to Efrati et al., the authors recommend the use of a “bundle approach” to infection prevention. 6. Describe your reaction to the source. The statistical analyses performed in this study seem to be thorough and reliable as the relevant data its accounted for in the article and the authors’ numerous sources are properly cited. However, the authors could have chosen a more current study from which to base their research.

Shibu, B., Susan, B., Nair, S., Ganesan, S., Bipin, R., & Sahagun, M. (2011). Implementation and compliance to ventilator associated pneumonia prevention bundle in a private health care facility in the United Arab Emirates. Journal of Critical Care, 26(5), E37. doi: 10.1016/j.jcrc.2011.05.033

1. Describe the content (focus) of the source. This source details the effects of a bundle of standard procedures adopted by a UAE critical care facility in order to prevent VAP infection. The source details the individual procedures put into practice and explains their purposes and intents. Additionally, the source describes the VAP training that the clinical staff underwent in order to learn how to properly and consistently implement the new practices. The study compares the rate of VAP infection in patients before the implementation of the bundle to the rate of infection in the two months following the bundle practice. 2. Describe the usefulness of the source. This source is useful because it’s analysis simply and clearly shows how a critical care facility can decrease its rate of patient VAP infection through adopting a preventative bundle approach to intubation and educating and training its staff accordingly with minimal cost and effort Additionally, the bundle identified in this source takes certain measures, such as the use of anticoagulants and chest physiotherapy, into consideration while my other sources do not.  3. Discuss any limitations that the source may have. This study does not evaluate the efficacy of the individual procedures that combine the bundle treatment. Due to this, the study does not establish causality between any one practice in the bundle and VAP infection. 4. Describe the audience that the source is intended for. This source is intended for critical care staff and administration. 5. Discuss the authors’ conclusions. The authors of this article conclude that the implementation of the bundle preventative resulted in a sustainable decrease in VAP infection and that “Education sessions designed to inform nurses about importance of ventilator bundle and its use to prevent VAP have had a significant effect in improving the knowledge level, which, in turn, has improved the clinical practice.” (Shibu et al., 2011, p. 37) 6. Describe your reaction to the source. I think this source is useful because it demonstrates a causal link between personnel training in prevention and significant VAP reduction. I also think it is useful as it contributes several additional suggestions of preventative practices to be included bundle approaches.

Winters, B. D., & Berenholtz, S. M. (2013, March). Ventilator Associate Pneumonia: Brief Update Review. Making Health Care Safer II. Retrieved August 4, 2013, from  http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html

1. Describe the content (focus) of the source. This source provides an overview of the preventative procedures that have been implemented with VAP in mind and explains them in terms of their practice and efficacy. Additionally, this source reviews recently-learned details of VAP infection prevention and describes the kinds of training and education that have been put into place to reduce rates of infection in patients. 2. Describe the usefulness of the source. This source is useful because of its comparative overview of general prevention practices and their efficacy. This source is also useful in that it details how VAP preventative practices have been implemented. 3. Discuss any limitations that the source may have. This source attempts to make broad generalizations about how preventative care for VAP is currently practiced. It does not consider how new studies and research might influence the current standard of care. 4. Describe the audience that the source is intended for. This source is intended for researchers and clinicians. 5. Discuss the authors’ conclusions. This article concludes that preventative bundles should be promoted and adopted and that it is essential that critical care personnel be thoroughly trained in their execution. Additionally, this source suggests that the efficacy of VAP preventative bundles may be due to a synergistic effect produced by the individual procedures with one another and that Finally, this source suggests two interesting ideas: that the efficacy of bundle treatments may be due to a synergistic relationship between the individual procedures of the bundle and that “bundles should be developed locally based on both institutional expertise and evidence, with ongoing evaluation of the success of the interventions” (Winters and Berenholtz, 2013, p. 116) 6. Describe your reaction to the source. I think that this source is credible because of its use of statistical analysis and evidence-based research. Moreover, this source offers a novel understanding of VAP prevention by suggestion a synergistic relationship of bundle practices and the customization of these practices based on institutional locality and staff specialization.

(Appendix omitted for preview. Available via download)

References

Bouza, E., Granda, M. J., Hortal, J., Barrio, J. M., Cercanado, E., & Munoz, P. (2013, September). Pre-emptive broad-spectrum treatment for ventilator-associated pneumonia in high-risk patients. National Center for Biotechnology Information. doi: 10.1007/s00134-013-2997-6

Canton-Potsdam Hospital marks full year without any ventilator-related pneumonias NorthCountryNow. (2013, July 15). North Country Now. Retrieved August 4, 2013, from http://northcountrynow.com/news/canton-potsdam-hospital-marks-full-year-without-any-ventilator-related-pneumonias-090905

Centers for Disease Control and Prevention. (2012, May 17). Retrieved from http://www.cdc.gov/HAI/vap/vap.html

Efrati, S., Deutsch, I., Antonelli, M., Hockey, P. M., Rozenblum, R., & Gurman, G. M. (2010). Ventilator-associated pneumonia: Current status and future recommendations. Journal of Clinical Monitoring and Computing, 24(2), 161-168. doi: 10.1007/s10877-010-9228-2

John, S., Karlnoski, R., Manger, D., Koll, J., Munoz, G., Thompson, P., ... Camporesi, E. M. (2013). Impact of a Low-Pressure Polyurethane Adult Endotracheal Tube on the Incidence of Ventilator-Associated Pneumonia: A before and after Concurrence Study. ISRN Critical Care, 2013, 1-6. doi: 812964

Koenig, S. M., & Truwit, J. D. (2006). Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention. Clinical Microbiology Reviews, 19(4), 637-657. doi: 10.1128/CMR.00051-05

Restrepo, M., Anzueto, A., Arroliga, A., Afessa, B., Atkinson, M., Ho, N., ... Kollef, M. (2010). Economic Burden of Ventilator‐Associated Pneumonia Based on Total Resource Utilization. Infection Control and Hospital Epidemiology, 31(5), 509-515. doi: 10.1086/651669

Shibu, B., Susan, B., Nair, S., Ganesan, S., Bipin, R., & Sahagun, M. (2011). Implementation and compliance to ventilator associated pneumonia prevention bundle in a private health care facility in the United Arab Emirates. Journal of Critical Care, 26(5), E37. doi: 10.1016/j.jcrc.2011.05.033

Winters, B. D., & Berenholtz, S. M. (2013, March). Ventilator Associate Pneumonia: Brief Update Review. Making Health Care Safer II. Retrieved August 4, 2013, from http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html