- Email: [email protected]
The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle
G Model JIPH-1196; No. of Pages 6
ARTICLE IN PRESS Journal of Infection and Public Health xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
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 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 b
a r t i c l e
i n f o
Article history: Received 22 February 2019 Received in revised form 28 July 2019 Accepted 24 September 2019 Keywords: Ventilator-associated pneumonia VAP VAP Bundle PICU
a b s t r a c t Introduction: Ventilator-associated pneumonia (VAP) is a nosocomial infection that develops 48 h after the initiation of mechanical ventilatory support. Current evidence-based guidelines demonstrate that VAP prevention is feasible through the implementation of certain VAP prevention bundle of interventions simultaneously. We aimed in this study to investigate the effect of VAP prevention pre- and postimplementation. Methods: This is a single-center, cohort study that took place at the Pediatric Intensive Care Unit (PICU) of King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia from January 2015 to March 2018 and assessed the rate of VAP before and after implementation of the bundle. 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 Ventilator-associated pneumonia (VAP) is a nosocomial infection that is not present at the time of intubation of patients requiring ventilation and develops more than 48 h after the initiation 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 Rosenthal 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: [email protected], [email protected] (Y.M. Al Talhi).
with pooled cumulative incidence of 22.8% among mechanically 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, mechanical 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 Organization (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/).
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model JIPH-1196; No. of Pages 6
ARTICLE IN PRESS S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx
2
Table 1 Ventilator-associated pneumonia (VAP) prevention bundle’s components which were developed after reviewing the medical literature with corresponding references.
Bundle components as whole
VAP bundle components
The references
Elevating Bed’s Head 30◦ –45◦ , reviewed every shift by the nurse in charge, to avoid aspiration of oropharynx secretions Providing mouth hygiene through chlorhexidine 2% oral kits 4 times per day to reduce oropharynx colonization Keeping ventilator circuits clean and dry through endotracheal tube (ETT) aspiration 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 Using cuffed ETT to avoid aspiration of oropharynx secretions Sedation holiday for deeply sedated patients every morning Using anti-reflex prophylaxis
[6,17]
The bundle was applied through a process of quality improvement using close monitoring and monthly auditing as a tool of staff stimulation 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%, Specificity = 75%) [5,13–17]. A subject would be diagnosed with VAP if: chest X-ray showed new infiltrates and at least 2 of the following 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-thenature 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 setting; this included the Fractioned Inspired Oxygen (FiO2 ) (>50%), Mean Airway Pressure (MAP) (>14 cmH2 O), and high Positive EndExpiratory 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 ventilation days, admission days, and the percentage of compliance with VAP bundle components during the period of the bundle application. The VAP prevention bundle followed in this study was a combination of evidence-based bundles from the medical literature.
[12,17–20] [12,17,21]
[12,17] [17] [6,17,18,22] [12,23]
Table 1 illustrates the VAP Bundle developed for this study with corresponding references. The bundle was approved prior to application by PICU head section, PICU nurse manager, hospital nurse educator, infection control department, and hospital administration. Once the items of the VAP bundle were ready to be applied, interventions were planned to fully orient PICU staff and to incorporate 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 formally presenting the program by the PICU Director or the nurse in-charge in all shifts; it included information about the development 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 elements 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. Periodical 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 distribution of the variables. The incidence rate of VAP was calculated as discrete number per 1000 Mechanical Ventilator Day. Quantitative 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
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model
ARTICLE IN PRESS
JIPH-1196; No. of Pages 6
S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx
3
Fig. 1. Study design explained in details. Table 2 Descriptive statistics comparing pre-bundle group to bundle group. Variables
Pre-bundle n = 95
bundle n = 36
p-Value
Median age in months (IQR) Male gender (%) Underlying medical disease category (%) • Metabolic/neurological • Respiratory • Oncology • Immunodeficiencyd • Cardiac • Others
12 (6) 53 (56)
15 (17) 16 (44)
0.733a 0.246b
10 (11) 40 (42) 11 (2) 7 (7) 9 (10) 18 (19)
4 (11) 15 (42) 6 (17) 2 (6) 4 (11) 5 (14)
0.954b
Ventilation mode (%) • Endotracheal tube • Tracheostomy tube
86 (90.5) 9 (9.5)
33 (92) 3 (8)
0.571b
Positive blood culture results (%) Positive respiratory culture results (%) High secretions (%) High fraction of inspired oxygen (%) High end expiratory positive airway pressure (%) High mean air-way pressure (%) High white blood cells (%) High C-reactive protein-CRP (%) Fever presence (%) Antibiotics usage (%) New infiltrates on chest X-ray (%)
14 (15) 45 (47) 33 (35) 54 (57) 45 (47) 39 (41) 48 (51) 44 (46) 51 (54) 57 (60) 59 (62)
4 (11) 15 (42) 19 (53) 18 (50) 14 (39) 17 (47) 19 (53) 15 (42) 15 (42) 23 (64) 15 (50)
0.901b 0.267b 0.060b 0.482b 0.384b 0.524b 0.818b 0.926b 0.219b 0.421b 0.209b
Development of VAP (%) • Early • Late
11 (11.58) 22 (23.16)
5 (13.89) 6 (16.67)
0.706
Overall development of ventilator associated pneumonia (VAP) (%) Median VAP ventilator days (IQR) Death due to VAP (%) VAP rate per 1000 ventilator days
33 (34.74) 14 (12) 6 (6) 18
11 (30.50) 10 (9) 1(3) 12
0.651b 0.757a 0.7648c 0.127
a b c d
Mann–Whitney test with 95% confidence interval. Using chi-square test with 95% confidence interval. Using Spearman’s rho test with 95% confidence interval. 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 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 and 12 per 1000 ventilator days, respectively (p = 0.127). Table 2 illustrates the demographic characteristics of both pre and postbundle groups. The ventilation mode in both groups was mostly endotracheal tube, 95% and 92% respectively. Antibiotics usage in both groups was above 60%. The compliance to the VAP bundle was 60% in the first 6 months and 80% in the latter 6. Table 3 details the
Table 3 Compliance rate to bundle application per items. Bundle components
Range of compliance rate
Oral chlorohexidine usage Hand washing Head positioning Changing ventilator circuit Anti-reflux usage Sedation holiday Using cuffed tubes
60–80% 80% 40–70% 70–90% 60–80% 20–40% 30–60%
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model JIPH-1196; No. of Pages 6
ARTICLE IN PRESS S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx
4
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) Male gender (%) Underlying medical disease category (%) • Metabolic/neurological • Respiratory • Oncology • Immunodeficiencyc • Cardiac • Others Ventilation mode (%) • Endotracheal tube • Tracheostomy tube High secretions (%) High fraction of inspired oxygen (%) High positive airway pressure (%) High mean air-way pressure (%) High white blood cells (%) High C-reactive protein (CRP) Fever presence (%) Antibiotics usage (%) New infiltrates on chest X-ray (%)
13.5 (10) 31 (50)
7 (30) 22 (67)
0.089a 0.119b
5 (8) 31 (50) 7 (11) 3 (5) 4 (6) 12 (19)
5 (15) 9 (27) 4 (12) 4 (12) 5 (15) 6 (18)
0.223b
55 (89) 7 (11) 28 (45) 25 (40) 19 (31) 14 (23) 26 (42) 20 (32) 25 (40) 37 (60) 26 (42)
31 (94) 2 (6) 5 (15) 29 (88) 26 (79) 25 (76) 22 (67) 24 (73) 26 (79) 20 (61) 33 (100)
0.407b 0.003b 0.000b 0.000b 0.000b 0.022b 0.000b 0.000b 0.930b 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) Male Sex (%) Underlying medical disease category (%) • Metabolic/neurological • Respiratory • Oncology • Immunodeficiencyc • Cardiac • Others Ventilation mode (%) • Endotracheal tube • Tracheostomy tube High secretions (%) High fraction of inspired oxygen (%) High positive airway pressure (%) High mean air-way pressure (%) High white blood cells (%) High C-reactive protein (CRP) Fever presence (%) Antibiotic usage (%) New infiltrates on chest X-ray (%)
12 (15) 9 (36)
17 (30) 7 (64)
0.359a 0.124b
2 (8) 11 (44) 4 (16) 2 (8) 2 (8) 4 (16)
2 (18) 4 (36) 2 (18) 0 2 (18) 1 (9)
0.747b
23 (92) 2 (8) 14 (56) 9 (36) 6 (24) 8 (32) 11 (44) 10 (40) 8 (32) 14 (56) 7 (28)
10 (91) 1 (9) 5 (45) 9 (82) 8 (73) 9 (82) 8 (73) 7 (64) 7 (64) 9 (82) 11 (100)
0.913b 0.559b 0.11b 0.006b 0.006b 0.112b 0.192b 0.080b 0.137b 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)
Oral chlorohexidine usage (%) Hand washing (%) Head positioning (%) Changing ventilator circuit (%) Anti-reflux usage (%) Sedation holiday (%) Using cuffed tubes (%) *
Development of VAP among the post bundle group No n = 25 (100%)
Yes n = 11 (100%)
15 (60) 20 (80) 11 (44) 20 (80) 13 (52) 6 (24) 12 (48)
8 (73) 9 (82) 4 (36) 10 (91) 8 (73) 2 (18) 6 (55)
p-Value*
0.464 0.899 0.669 0.418 0.245 0.699 0.717
Using chi-square test with 95% confidence interval.
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model
ARTICLE IN PRESS
JIPH-1196; No. of Pages 6
S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx Table 7 Comparison between patients who developed ventilator-associated pneumonia (VAP) among the pre-bundle group to those in the bundle group in terms of the respiratory culture isolates.a Respiratory isolatesb
Pseudomonas aeruginosa Klebsiella pneumoniae Stenotrophomonas maltophilia Acinetobacter baumanii Enterobacter cloacae Escherichia coli Staphylococcus aureus Haemophilus influenzae Streptococcus pneumoniae Moraxella catarrhalis Serratia marcescens Un-identified Gram -ve Bacilli
Respiratory isolatesb
Development of VAP (n = 44) Pre-bundle n = 33 (100%)
Post-bundle n = 11 (100%)
12d (36)
3c (27)
4e (12) 5 (15)
4 (36) 1 (9)
4c (12) 3c (9) 2 (6) 3f (9) 2 (6) 2 (6)
1 (9) 1c (9) 1 (9) – – –
1 (3) 1 (3) 1(3)
– – –
a No statistical significance was found by using Fisher-exact test with 95% confidence interval where applicable. b Many of the respiratory specimens had more than one isolate at a time. c One isolate was carbapenem resistant. d 5 isolates were carbapenem resistant. e Tow isolates were carbapenem resistant. f Two isolates were Methicillin-resistant Staphylococcus aureus.
over-all rates of compliance to the bundle elements from the PICU team. Table 4 shows the comparison between patients who developed VAP with those who did not in the pre-bundle group. The VAP group had a significantly higher rate of positive respiratory cultures, high positive airway pressure, high mean airway pressure, high Oxygen requirements, high white blood count (WBC) and high C-reactive protein (CRP). VAP subjects were also significantly more likely to have fever and new infiltrates on chest X-ray. Having increased secretions was, however, more documented in the non-VAP subjects. Table 5, on the other hand, demonstrates the same comparison in the post-bundle group. On the contrary to the pre-bundle group, subjects with VAP in the post-bundle group had only significantly higher rate of positive respiratory cultures, high positive airway pressure, high mean airway pressure, as well as having new infiltrates on chest X-ray. There was no significant difference in the rate of fever, increased WBC or CRP. The age was not normally distributed in the three tables (p-value < 0.0001 using Kolmogorov–Smirnov Test); thus, the median and range were reported. Further comparison was done between patients who developed VAP and those who did not regarding the compliance to VAP Bundle elements (Table 6). This comparison showed no statistically significant difference between the two groups indicating that the compliance rate among those patients were similar (whether low or high). Respiratory culture isolates among patients who developed VAP in the pre- and post- bundle groups are summarized in Table 7. Infection caused by Carbapenem-resistant gram-negative organisms was reported in 25% (11/44) of all VAP cases; this rate dropped from 26% in the pre-bundle group to 18% in the post-bundle group yet was not statistically significant (p = 1.0). Discussion In this study, after 1 year of implementation, no statistically significant change was found in VAP rate between pre- and post- VAP prevention bundle.
5
Literature of examining bundle effectiveness in PICU settings is limited. Bigham et al. caught sight of VAP prevention bundle effectiveness as VAP incidence rate significantly reduced from 5.6 to 0.3 VAP per 1000 Mechanical Ventilator Day (p < 0.0001) after bundle application [18]. Similarly, De Cristofano et al. found out that the rate of VAP has significantly decrease from 13.2% to 4.5% with an incidence density equaled to 6.34 and 2.38 VAP per 1000 Mechanical Ventilator Day, respectively (p = 0.0047) [19]. On an international, multi-PICUs participation level, Rosenthal et al. also found that application of VAP prevention bundle has decrease VAP rate from 4.8% to 2.6% with incidence intensities being 11.7 and 8.1 VAP per 1000 Mechanical Ventilator Day (p = 0.0286) [20]. On the contrary, yet similar to our study, Pena-Lopez et al. revealed an insignificant difference of VAP rate pre- (4.14 per 1000 Mechanical Ventilator Day) and post- (2.68 and 1.05 per 1000 Mechanical Ventilator Day) VAP prevention bundle (p = 0.088) [21]. Examining VAP prevention bundle was of a greater extent among neonates and adults. For example, Azab et al. brought off that VAP rate in the neonatal intensive care unit (NICU) significantly reduced from 68% with 36 VAP per per 1000 Mechanical Ventilator Day to 38% with 23 VAP per 1000 Mechanical Ventilator Day after Bundle application (p = 0.0006). In addition, among adults, Lerma et al. brought the light to an impressively significant reduction of VAP rate from 2.4% (n = 539) to 1.9% (n = 3186); p = <0.0001 with 7 VAP per 1000 Mechanical Ventilator Day to the latter [22]. Similarly, to this study, Amanati et al. concluded that age, sex and antibiotics usage was not significantly associated to the development of VAP, however, compromised immune status is (p = 0.014) [3]. A meta-analysis study also showed that the latter variables were not significant for VAP development; other risk factors to develop VAP, of which were not gone through in this study, have been examined, too [23]. An apt usage of antibiotics should also be considered for the opposite can aggregate the risk for multidrug resistance organism and mortality [24]. It is worth to mention that many countries adopted different approaches for VAP prevention; one of which is the International Nosocomial Infection Control Consortium (INICC), which includes multidimensional approaches constituting the application of 6 components for VAP prevention; these include: bundle application for infection prevention, education, outcome surveillance, process surveillance, VAP rate feedback, and performance feedback [25]. Rosthenal et al. demonstrated in a multicenter study that included NICUs in 10 developing countries that the implementation of the (INICC) multidimensional infection prevention program was associated with significant reduction in VAP rate (Relative risk of 0.67; p = 0.001) [26]. Another approach was the “Zero-VAP” bundle, which was initiated by the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses. This includes guidelines for prevention of VAP using surveillance database on VAP episodes, which is classified into three main sets of methods; a functional set, a mechanical set, and a pharmacological set [27]. The compliance to VAP prevention bundle appeared as a “game changer” in the literature. For example, the adherence to the bundle and its effectiveness were examined by Samra et al., and they concluded that the incidence of VAP decreased significantly between “non-bundle” and “bundle” groups (18.5% vs 9%, p < 0.05) with minimal adherence rate of 94% per month. The authors highlighted that “zero-VAP” has been attained in many months, and it required considerable awareness to the bundle items and a very firm adherence by labelling the bundle as a local policy [28]. Similarly, by plotting both bundle compliance and VAP rate per month, Caserta et al. found out that the rate of VAP reached zero in many months once the compliance exceeded 95% [29]. Those findings suggest that the bundle could tackle the VAP rate, and its impact is not “Delphic”; however, it could be clouded by the compliance rate. Therefore, we believe that with higher compliance rate (up to 95%) would help
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model JIPH-1196; No. of Pages 6
ARTICLE IN PRESS S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx
6
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 involvement, 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 prospective, 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. References [1] Kollef MH. What is ventilator-associated pneumonia and why is it important? Respir Care 2005;50(6):714–24. [2] Rosenthal VD, et al. International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: device-associated module. Am J Infect Control 2016;44(12):1495–504. [3] Amanati A, et al. Incidence of ventilator-associated pneumonia in critically ill children undergoing mechanical ventilation in pediatric Intensive Care Unit. Children 2017;4(7):56. [4] O’horo JC, Thompson D, Safdar N. Is the gram stain useful in the microbiologic diagnosis of VAP? A meta-analysis. Clin Infect Dis 2012;55(4):551–61. [5] Hunter JD. Ventilator associated pneumonia. BMJ 2012;344(e3325):e3225.
[6] Kollef MH. Ventilator-associated pneumonia prevention. Is it worth it? American Thoracic Society; 2015. [7] Hellyer TP, et al. The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. J Intensive Care Soc 2016;17(3):238–43. [8] Wip C, Napolitano L. Bundles to prevent ventilator-associated pneumonia: how valuable are they? Curr Opin Infect Dis 2009;22(2):159–66. [9] Cooper VB, Haut C. Preventing ventilator-associated pneumonia in children: an evidence-based protocol. Crit Care Nurse 2013;33(3):21–9, quiz 30. [10] Wahl WL, et al. Intensive care unit core measures improve infectious complications in burn patients. J Burn Care Res 2010;31(1):190–5. [11] Al-Tawfiq JA, Abed MS. Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle. Am J Infect Control 2010;38(7):552–6. [12] Society AT, I.D.S.O. America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171(4):388. [13] Foglia E, Meier MD, Elward A. Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients. Clin Microbiol Rev 2007;20(3):409–25, table of contents. [14] Rea-Neto A, et al. Diagnosis of ventilator-associated pneumonia: a systematic review of the literature. Crit Care 2008;12(2):R56. [15] Lambert M-L, et al. Prevention of ventilator-associated pneumonia in intensive care units: an international online survey. Antimicrob Resist Infect Control 2013;2(1):9. [16] Johanson WG, et al. Nosocomial respiratory infections with gram-negative bacilli: the significance of colonization of the respiratory tract. Ann Intern Med 1972;77(5):701–6. [17] Koenig Á, et al. Comparing CDC’s surveillance definitions and CPIS score in diagnosing ventilator-associated pneumonia: an observational study. Crit Care 2015;19(2):P61. [18] Bigham MT, et al. Ventilator-associated pneumonia in the pediatric intensive care unit: characterizing the problem and implementing a sustainable solution. J Pediatr 2009;154(4):582–7, e2. [19] De Cristofano A, et al. Implementation of a ventilator-associated pneumonia prevention bundle in a single PICU. Pediatr Crit Care Med 2016;17(5):451–6. [20] Rosenthal VD, et al. Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings. Am J Infect Control 2012;40(6):497–501. [21] Pena-Lopez Y, et al. Implementing a care bundle approach reduces ventilatorassociated pneumonia and delays ventilator-associated tracheobronchitis in children: differences according to endotracheal or tracheostomy devices. Int J Infect Dis 2016;52:43–8. [22] Álvarez-Lerma F, et al. Prevention of ventilator-associated pneumonia: the multimodal approach of the Spanish ICU “Pneumonia Zero” program. Crit Care Med 2018;46(2):181. [23] Liu B, et al. Risk factors of ventilator-associated pneumonia in pediatric intensive care unit: a systematic review and meta-analysis. J Thorac Dis 2013;5(4):525. [24] Dupont H, et al. Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator-associated pneumonia. Intensive Care Med 2001;27(2):355–62. [25] Rosenthal VD. International Nosocomial Infection Control Consortium (INICC) resources: INICC multidimensional approach and INICC surveillance online system. Am J Infect Control 2016;44(6):e81–90. [26] Rosenthal VD, et al. Findings of the International Nosocomial Infection Control Consortium (INICC), part II: impact of a multidimensional strategy to reduce ventilator-associated pneumonia in neonatal intensive care units in 10 developing countries. Infect Control Hosp Epidemiol 2012;33(7):704–10. [27] Lerma FÁ, et al. Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish “Zero-VAP” bundle. Med Intensiva 2014;38(4):226–36. [28] Samra SR, Sherif DM, Elokda SA. Impact of VAP bundle adherence among ventilated critically ill patients and its effectiveness in adult ICU. Egypt J Chest Dis Tuberc 2017;66(1):81–6. [29] Caserta RA, et al. A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting. BMC Infect Dis 2012;12(1):234.
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
ARTICLE IN PRESS Journal of Infection and Public Health xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
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 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 b
a r t i c l e
i n f o
Article history: Received 22 February 2019 Received in revised form 28 July 2019 Accepted 24 September 2019 Keywords: Ventilator-associated pneumonia VAP VAP Bundle PICU
a b s t r a c t Introduction: Ventilator-associated pneumonia (VAP) is a nosocomial infection that develops 48 h after the initiation of mechanical ventilatory support. Current evidence-based guidelines demonstrate that VAP prevention is feasible through the implementation of certain VAP prevention bundle of interventions simultaneously. We aimed in this study to investigate the effect of VAP prevention pre- and postimplementation. Methods: This is a single-center, cohort study that took place at the Pediatric Intensive Care Unit (PICU) of King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia from January 2015 to March 2018 and assessed the rate of VAP before and after implementation of the bundle. 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 Ventilator-associated pneumonia (VAP) is a nosocomial infection that is not present at the time of intubation of patients requiring ventilation and develops more than 48 h after the initiation 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 Rosenthal 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: [email protected], [email protected] (Y.M. Al Talhi).
with pooled cumulative incidence of 22.8% among mechanically 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, mechanical 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 Organization (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/).
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model JIPH-1196; No. of Pages 6
ARTICLE IN PRESS S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx
2
Table 1 Ventilator-associated pneumonia (VAP) prevention bundle’s components which were developed after reviewing the medical literature with corresponding references.
Bundle components as whole
VAP bundle components
The references
Elevating Bed’s Head 30◦ –45◦ , reviewed every shift by the nurse in charge, to avoid aspiration of oropharynx secretions Providing mouth hygiene through chlorhexidine 2% oral kits 4 times per day to reduce oropharynx colonization Keeping ventilator circuits clean and dry through endotracheal tube (ETT) aspiration 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 Using cuffed ETT to avoid aspiration of oropharynx secretions Sedation holiday for deeply sedated patients every morning Using anti-reflex prophylaxis
[6,17]
The bundle was applied through a process of quality improvement using close monitoring and monthly auditing as a tool of staff stimulation 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%, Specificity = 75%) [5,13–17]. A subject would be diagnosed with VAP if: chest X-ray showed new infiltrates and at least 2 of the following 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-thenature 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 setting; this included the Fractioned Inspired Oxygen (FiO2 ) (>50%), Mean Airway Pressure (MAP) (>14 cmH2 O), and high Positive EndExpiratory 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 ventilation days, admission days, and the percentage of compliance with VAP bundle components during the period of the bundle application. The VAP prevention bundle followed in this study was a combination of evidence-based bundles from the medical literature.
[12,17–20] [12,17,21]
[12,17] [17] [6,17,18,22] [12,23]
Table 1 illustrates the VAP Bundle developed for this study with corresponding references. The bundle was approved prior to application by PICU head section, PICU nurse manager, hospital nurse educator, infection control department, and hospital administration. Once the items of the VAP bundle were ready to be applied, interventions were planned to fully orient PICU staff and to incorporate 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 formally presenting the program by the PICU Director or the nurse in-charge in all shifts; it included information about the development 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 elements 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. Periodical 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 distribution of the variables. The incidence rate of VAP was calculated as discrete number per 1000 Mechanical Ventilator Day. Quantitative 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
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model
ARTICLE IN PRESS
JIPH-1196; No. of Pages 6
S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx
3
Fig. 1. Study design explained in details. Table 2 Descriptive statistics comparing pre-bundle group to bundle group. Variables
Pre-bundle n = 95
bundle n = 36
p-Value
Median age in months (IQR) Male gender (%) Underlying medical disease category (%) • Metabolic/neurological • Respiratory • Oncology • Immunodeficiencyd • Cardiac • Others
12 (6) 53 (56)
15 (17) 16 (44)
0.733a 0.246b
10 (11) 40 (42) 11 (2) 7 (7) 9 (10) 18 (19)
4 (11) 15 (42) 6 (17) 2 (6) 4 (11) 5 (14)
0.954b
Ventilation mode (%) • Endotracheal tube • Tracheostomy tube
86 (90.5) 9 (9.5)
33 (92) 3 (8)
0.571b
Positive blood culture results (%) Positive respiratory culture results (%) High secretions (%) High fraction of inspired oxygen (%) High end expiratory positive airway pressure (%) High mean air-way pressure (%) High white blood cells (%) High C-reactive protein-CRP (%) Fever presence (%) Antibiotics usage (%) New infiltrates on chest X-ray (%)
14 (15) 45 (47) 33 (35) 54 (57) 45 (47) 39 (41) 48 (51) 44 (46) 51 (54) 57 (60) 59 (62)
4 (11) 15 (42) 19 (53) 18 (50) 14 (39) 17 (47) 19 (53) 15 (42) 15 (42) 23 (64) 15 (50)
0.901b 0.267b 0.060b 0.482b 0.384b 0.524b 0.818b 0.926b 0.219b 0.421b 0.209b
Development of VAP (%) • Early • Late
11 (11.58) 22 (23.16)
5 (13.89) 6 (16.67)
0.706
Overall development of ventilator associated pneumonia (VAP) (%) Median VAP ventilator days (IQR) Death due to VAP (%) VAP rate per 1000 ventilator days
33 (34.74) 14 (12) 6 (6) 18
11 (30.50) 10 (9) 1(3) 12
0.651b 0.757a 0.7648c 0.127
a b c d
Mann–Whitney test with 95% confidence interval. Using chi-square test with 95% confidence interval. Using Spearman’s rho test with 95% confidence interval. 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 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 and 12 per 1000 ventilator days, respectively (p = 0.127). Table 2 illustrates the demographic characteristics of both pre and postbundle groups. The ventilation mode in both groups was mostly endotracheal tube, 95% and 92% respectively. Antibiotics usage in both groups was above 60%. The compliance to the VAP bundle was 60% in the first 6 months and 80% in the latter 6. Table 3 details the
Table 3 Compliance rate to bundle application per items. Bundle components
Range of compliance rate
Oral chlorohexidine usage Hand washing Head positioning Changing ventilator circuit Anti-reflux usage Sedation holiday Using cuffed tubes
60–80% 80% 40–70% 70–90% 60–80% 20–40% 30–60%
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model JIPH-1196; No. of Pages 6
ARTICLE IN PRESS S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx
4
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) Male gender (%) Underlying medical disease category (%) • Metabolic/neurological • Respiratory • Oncology • Immunodeficiencyc • Cardiac • Others Ventilation mode (%) • Endotracheal tube • Tracheostomy tube High secretions (%) High fraction of inspired oxygen (%) High positive airway pressure (%) High mean air-way pressure (%) High white blood cells (%) High C-reactive protein (CRP) Fever presence (%) Antibiotics usage (%) New infiltrates on chest X-ray (%)
13.5 (10) 31 (50)
7 (30) 22 (67)
0.089a 0.119b
5 (8) 31 (50) 7 (11) 3 (5) 4 (6) 12 (19)
5 (15) 9 (27) 4 (12) 4 (12) 5 (15) 6 (18)
0.223b
55 (89) 7 (11) 28 (45) 25 (40) 19 (31) 14 (23) 26 (42) 20 (32) 25 (40) 37 (60) 26 (42)
31 (94) 2 (6) 5 (15) 29 (88) 26 (79) 25 (76) 22 (67) 24 (73) 26 (79) 20 (61) 33 (100)
0.407b 0.003b 0.000b 0.000b 0.000b 0.022b 0.000b 0.000b 0.930b 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) Male Sex (%) Underlying medical disease category (%) • Metabolic/neurological • Respiratory • Oncology • Immunodeficiencyc • Cardiac • Others Ventilation mode (%) • Endotracheal tube • Tracheostomy tube High secretions (%) High fraction of inspired oxygen (%) High positive airway pressure (%) High mean air-way pressure (%) High white blood cells (%) High C-reactive protein (CRP) Fever presence (%) Antibiotic usage (%) New infiltrates on chest X-ray (%)
12 (15) 9 (36)
17 (30) 7 (64)
0.359a 0.124b
2 (8) 11 (44) 4 (16) 2 (8) 2 (8) 4 (16)
2 (18) 4 (36) 2 (18) 0 2 (18) 1 (9)
0.747b
23 (92) 2 (8) 14 (56) 9 (36) 6 (24) 8 (32) 11 (44) 10 (40) 8 (32) 14 (56) 7 (28)
10 (91) 1 (9) 5 (45) 9 (82) 8 (73) 9 (82) 8 (73) 7 (64) 7 (64) 9 (82) 11 (100)
0.913b 0.559b 0.11b 0.006b 0.006b 0.112b 0.192b 0.080b 0.137b 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)
Oral chlorohexidine usage (%) Hand washing (%) Head positioning (%) Changing ventilator circuit (%) Anti-reflux usage (%) Sedation holiday (%) Using cuffed tubes (%) *
Development of VAP among the post bundle group No n = 25 (100%)
Yes n = 11 (100%)
15 (60) 20 (80) 11 (44) 20 (80) 13 (52) 6 (24) 12 (48)
8 (73) 9 (82) 4 (36) 10 (91) 8 (73) 2 (18) 6 (55)
p-Value*
0.464 0.899 0.669 0.418 0.245 0.699 0.717
Using chi-square test with 95% confidence interval.
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model
ARTICLE IN PRESS
JIPH-1196; No. of Pages 6
S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx Table 7 Comparison between patients who developed ventilator-associated pneumonia (VAP) among the pre-bundle group to those in the bundle group in terms of the respiratory culture isolates.a Respiratory isolatesb
Pseudomonas aeruginosa Klebsiella pneumoniae Stenotrophomonas maltophilia Acinetobacter baumanii Enterobacter cloacae Escherichia coli Staphylococcus aureus Haemophilus influenzae Streptococcus pneumoniae Moraxella catarrhalis Serratia marcescens Un-identified Gram -ve Bacilli
Respiratory isolatesb
Development of VAP (n = 44) Pre-bundle n = 33 (100%)
Post-bundle n = 11 (100%)
12d (36)
3c (27)
4e (12) 5 (15)
4 (36) 1 (9)
4c (12) 3c (9) 2 (6) 3f (9) 2 (6) 2 (6)
1 (9) 1c (9) 1 (9) – – –
1 (3) 1 (3) 1(3)
– – –
a No statistical significance was found by using Fisher-exact test with 95% confidence interval where applicable. b Many of the respiratory specimens had more than one isolate at a time. c One isolate was carbapenem resistant. d 5 isolates were carbapenem resistant. e Tow isolates were carbapenem resistant. f Two isolates were Methicillin-resistant Staphylococcus aureus.
over-all rates of compliance to the bundle elements from the PICU team. Table 4 shows the comparison between patients who developed VAP with those who did not in the pre-bundle group. The VAP group had a significantly higher rate of positive respiratory cultures, high positive airway pressure, high mean airway pressure, high Oxygen requirements, high white blood count (WBC) and high C-reactive protein (CRP). VAP subjects were also significantly more likely to have fever and new infiltrates on chest X-ray. Having increased secretions was, however, more documented in the non-VAP subjects. Table 5, on the other hand, demonstrates the same comparison in the post-bundle group. On the contrary to the pre-bundle group, subjects with VAP in the post-bundle group had only significantly higher rate of positive respiratory cultures, high positive airway pressure, high mean airway pressure, as well as having new infiltrates on chest X-ray. There was no significant difference in the rate of fever, increased WBC or CRP. The age was not normally distributed in the three tables (p-value < 0.0001 using Kolmogorov–Smirnov Test); thus, the median and range were reported. Further comparison was done between patients who developed VAP and those who did not regarding the compliance to VAP Bundle elements (Table 6). This comparison showed no statistically significant difference between the two groups indicating that the compliance rate among those patients were similar (whether low or high). Respiratory culture isolates among patients who developed VAP in the pre- and post- bundle groups are summarized in Table 7. Infection caused by Carbapenem-resistant gram-negative organisms was reported in 25% (11/44) of all VAP cases; this rate dropped from 26% in the pre-bundle group to 18% in the post-bundle group yet was not statistically significant (p = 1.0). Discussion In this study, after 1 year of implementation, no statistically significant change was found in VAP rate between pre- and post- VAP prevention bundle.
5
Literature of examining bundle effectiveness in PICU settings is limited. Bigham et al. caught sight of VAP prevention bundle effectiveness as VAP incidence rate significantly reduced from 5.6 to 0.3 VAP per 1000 Mechanical Ventilator Day (p < 0.0001) after bundle application [18]. Similarly, De Cristofano et al. found out that the rate of VAP has significantly decrease from 13.2% to 4.5% with an incidence density equaled to 6.34 and 2.38 VAP per 1000 Mechanical Ventilator Day, respectively (p = 0.0047) [19]. On an international, multi-PICUs participation level, Rosenthal et al. also found that application of VAP prevention bundle has decrease VAP rate from 4.8% to 2.6% with incidence intensities being 11.7 and 8.1 VAP per 1000 Mechanical Ventilator Day (p = 0.0286) [20]. On the contrary, yet similar to our study, Pena-Lopez et al. revealed an insignificant difference of VAP rate pre- (4.14 per 1000 Mechanical Ventilator Day) and post- (2.68 and 1.05 per 1000 Mechanical Ventilator Day) VAP prevention bundle (p = 0.088) [21]. Examining VAP prevention bundle was of a greater extent among neonates and adults. For example, Azab et al. brought off that VAP rate in the neonatal intensive care unit (NICU) significantly reduced from 68% with 36 VAP per per 1000 Mechanical Ventilator Day to 38% with 23 VAP per 1000 Mechanical Ventilator Day after Bundle application (p = 0.0006). In addition, among adults, Lerma et al. brought the light to an impressively significant reduction of VAP rate from 2.4% (n = 539) to 1.9% (n = 3186); p = <0.0001 with 7 VAP per 1000 Mechanical Ventilator Day to the latter [22]. Similarly, to this study, Amanati et al. concluded that age, sex and antibiotics usage was not significantly associated to the development of VAP, however, compromised immune status is (p = 0.014) [3]. A meta-analysis study also showed that the latter variables were not significant for VAP development; other risk factors to develop VAP, of which were not gone through in this study, have been examined, too [23]. An apt usage of antibiotics should also be considered for the opposite can aggregate the risk for multidrug resistance organism and mortality [24]. It is worth to mention that many countries adopted different approaches for VAP prevention; one of which is the International Nosocomial Infection Control Consortium (INICC), which includes multidimensional approaches constituting the application of 6 components for VAP prevention; these include: bundle application for infection prevention, education, outcome surveillance, process surveillance, VAP rate feedback, and performance feedback [25]. Rosthenal et al. demonstrated in a multicenter study that included NICUs in 10 developing countries that the implementation of the (INICC) multidimensional infection prevention program was associated with significant reduction in VAP rate (Relative risk of 0.67; p = 0.001) [26]. Another approach was the “Zero-VAP” bundle, which was initiated by the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses. This includes guidelines for prevention of VAP using surveillance database on VAP episodes, which is classified into three main sets of methods; a functional set, a mechanical set, and a pharmacological set [27]. The compliance to VAP prevention bundle appeared as a “game changer” in the literature. For example, the adherence to the bundle and its effectiveness were examined by Samra et al., and they concluded that the incidence of VAP decreased significantly between “non-bundle” and “bundle” groups (18.5% vs 9%, p < 0.05) with minimal adherence rate of 94% per month. The authors highlighted that “zero-VAP” has been attained in many months, and it required considerable awareness to the bundle items and a very firm adherence by labelling the bundle as a local policy [28]. Similarly, by plotting both bundle compliance and VAP rate per month, Caserta et al. found out that the rate of VAP reached zero in many months once the compliance exceeded 95% [29]. Those findings suggest that the bundle could tackle the VAP rate, and its impact is not “Delphic”; however, it could be clouded by the compliance rate. Therefore, we believe that with higher compliance rate (up to 95%) would help
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015
G Model JIPH-1196; No. of Pages 6
ARTICLE IN PRESS S. Osman et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx
6
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 involvement, 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 prospective, 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. References [1] Kollef MH. What is ventilator-associated pneumonia and why is it important? Respir Care 2005;50(6):714–24. [2] Rosenthal VD, et al. International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: device-associated module. Am J Infect Control 2016;44(12):1495–504. [3] Amanati A, et al. Incidence of ventilator-associated pneumonia in critically ill children undergoing mechanical ventilation in pediatric Intensive Care Unit. Children 2017;4(7):56. [4] O’horo JC, Thompson D, Safdar N. Is the gram stain useful in the microbiologic diagnosis of VAP? A meta-analysis. Clin Infect Dis 2012;55(4):551–61. [5] Hunter JD. Ventilator associated pneumonia. BMJ 2012;344(e3325):e3225.
[6] Kollef MH. Ventilator-associated pneumonia prevention. Is it worth it? American Thoracic Society; 2015. [7] Hellyer TP, et al. The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. J Intensive Care Soc 2016;17(3):238–43. [8] Wip C, Napolitano L. Bundles to prevent ventilator-associated pneumonia: how valuable are they? Curr Opin Infect Dis 2009;22(2):159–66. [9] Cooper VB, Haut C. Preventing ventilator-associated pneumonia in children: an evidence-based protocol. Crit Care Nurse 2013;33(3):21–9, quiz 30. [10] Wahl WL, et al. Intensive care unit core measures improve infectious complications in burn patients. J Burn Care Res 2010;31(1):190–5. [11] Al-Tawfiq JA, Abed MS. Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle. Am J Infect Control 2010;38(7):552–6. [12] Society AT, I.D.S.O. America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171(4):388. [13] Foglia E, Meier MD, Elward A. Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients. Clin Microbiol Rev 2007;20(3):409–25, table of contents. [14] Rea-Neto A, et al. Diagnosis of ventilator-associated pneumonia: a systematic review of the literature. Crit Care 2008;12(2):R56. [15] Lambert M-L, et al. Prevention of ventilator-associated pneumonia in intensive care units: an international online survey. Antimicrob Resist Infect Control 2013;2(1):9. [16] Johanson WG, et al. Nosocomial respiratory infections with gram-negative bacilli: the significance of colonization of the respiratory tract. Ann Intern Med 1972;77(5):701–6. [17] Koenig Á, et al. Comparing CDC’s surveillance definitions and CPIS score in diagnosing ventilator-associated pneumonia: an observational study. Crit Care 2015;19(2):P61. [18] Bigham MT, et al. Ventilator-associated pneumonia in the pediatric intensive care unit: characterizing the problem and implementing a sustainable solution. J Pediatr 2009;154(4):582–7, e2. [19] De Cristofano A, et al. Implementation of a ventilator-associated pneumonia prevention bundle in a single PICU. Pediatr Crit Care Med 2016;17(5):451–6. [20] Rosenthal VD, et al. Effectiveness of a multidimensional approach to reduce ventilator-associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings. Am J Infect Control 2012;40(6):497–501. [21] Pena-Lopez Y, et al. Implementing a care bundle approach reduces ventilatorassociated pneumonia and delays ventilator-associated tracheobronchitis in children: differences according to endotracheal or tracheostomy devices. Int J Infect Dis 2016;52:43–8. [22] Álvarez-Lerma F, et al. Prevention of ventilator-associated pneumonia: the multimodal approach of the Spanish ICU “Pneumonia Zero” program. Crit Care Med 2018;46(2):181. [23] Liu B, et al. Risk factors of ventilator-associated pneumonia in pediatric intensive care unit: a systematic review and meta-analysis. J Thorac Dis 2013;5(4):525. [24] Dupont H, et al. Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator-associated pneumonia. Intensive Care Med 2001;27(2):355–62. [25] Rosenthal VD. International Nosocomial Infection Control Consortium (INICC) resources: INICC multidimensional approach and INICC surveillance online system. Am J Infect Control 2016;44(6):e81–90. [26] Rosenthal VD, et al. Findings of the International Nosocomial Infection Control Consortium (INICC), part II: impact of a multidimensional strategy to reduce ventilator-associated pneumonia in neonatal intensive care units in 10 developing countries. Infect Control Hosp Epidemiol 2012;33(7):704–10. [27] Lerma FÁ, et al. Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish “Zero-VAP” bundle. Med Intensiva 2014;38(4):226–36. [28] Samra SR, Sherif DM, Elokda SA. Impact of VAP bundle adherence among ventilated critically ill patients and its effectiveness in adult ICU. Egypt J Chest Dis Tuberc 2017;66(1):81–6. [29] Caserta RA, et al. A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting. BMC Infect Dis 2012;12(1):234.
Please cite this article in press as: Osman S, et al. The incidence of ventilator-associated pneumonia (VAP) in a tertiary-care center: Comparison between pre- and post-VAP prevention bundle. J Infect Public Health (2019), https://doi.org/10.1016/j.jiph.2019.09.015