- Email: [email protected]
Ventilator-associated pneumonia: Survey of infection control practices in intensive care units of 15 tertiary care hospitals in Mumbai
American Journal of Infection Control 42 (2014) 935-40
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Letters to the Editor
Ventilator-associated pneumonia: Survey of infection control practices in intensive care units of 15 tertiary care hospitals in Mumbai To the Editor: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in patients hospitalized in intensive care units (ICUs). Meticulous implementation of infection control measures is a key component for reducing the incidence of VAP. The Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Association for the Profession of Infection Control and Epidemiology, and Centers for Disease Control and Prevention provide guidelines1-3 that comprehensively review the infection control measures for VAP prevention and provide evidence-based recommendations. Studies have shown that the efficient implementation of VAP care bundles decreases the incidence of VAP4,5 and significantly improves outcomes. But although clear recommendations are now available for many components of these bundles (eg, semirecumbent patient positioning), there remain controversies over certain issues (eg, selective digestive tract decontamination). We conducted a survey to determine the VAP policies and practices in various Mumbai hospital ICUs and to compare them for uniformity and differences. A prestructured questionnaire designed to cover the important VAP prevention practices and procedures were circulated to participating hospitals in Mumbai. Respondents included 15 multispecialty tertiary care hospitals. The results of the survey are shown in Figure 1. Other relevant findings included the following. Closed suction systems were used by two-thirds of the respondents; 53.3% reported changing the suction system when it was soiled, 26.67% reported changing the system every 48 hours, and 13.3% reported changing the system every 24 hours. Sixty percent of respondents reported changing the ventilator circuit when it was soiled, 20% reported changing it at 48 hours, and 13.3% reported changing it at 7 days. Heat moisture exchanger humidifiers were used by all respondents; approximately 20% of respondents changed the humidifier at 24 hours, 53.33% did so at 48 hours and 13.33% did so after 72 hours. The important components of ventilator patient care aimed at reducing infection include preventing inspiration of oropharyngeal secretions, preventing contamination of equipment, preventing
colonization of the aerodigestive tract, implementating the VAP care bundle, maintaining meticulous practice, and consistently reinforcing general infection control practices.6 The points covered in this survey were intended to address the aforementioned aspects, which play major roles in reducing the incidence of VAP. One major discrepancy in practice noted in our survey was related to suctioning practices. The effect of closed suction systems on the incidence of VAP remains a matter of debate, with studies reporting inconsistent results. Reductions in colonization may be better achieved by the use of closed suction systems, which also permit continuous ventilation and is safer in view of the much lower risk of aerosolization and is recommended by the American Association for Respiratory Care.7 Another important step in preventing aspiration in ventilated patients is removing subglottic secretions that may accumulate above the endotracheal tube cuff. In patients expected to be ventilated for more than 72 hours, the use of a specialized endotracheal tube with an inbuilt system for subglottic suction to remove oropharyngeal secretions was effective in reducing earlyonset VAP, as demonstrated in a meta-analysis,8 and thus is recommended. The use of kinetic (ie, continuous lateral rotation) beds, although shown to be effective9 in reducing VAP, is limited by safety and cost concerns, as evidenced by its use in <15% of the settings in our survey. VAP practices have been reviewed in various surveys worldwide. Although most of these surveys agree on general principles, there are some differences with respect to prevalent practices and their compliance. Whereas the Centers for Disease Control and Prevention’s National Healthcare Safety Network 2006-2007 summary data10 identify Staphylococcus aureus (24.4%) as the organism most commonly implicated in VAP, followed by Pseudomonas aeruginosa (16.3%), Enterobacter spp (8.4%), Acinetobacter baumannii (8.4%), and Klebsiella pneumoniae (7.5%) were commonly implicated in VAPs, Pseudomonas and Acinetobacter, followed by Staphylococcus, were the common organisms reported in a survey from the Indian subcontinent.11 Our study showed that the common organisms in our setting are Acinetobacter spp, followed by K pneumoniae and P aeruginosa. Our data show a wide variation in VAP rates, ranging from 2.2 to 47 per 1000 ventilator-days, indicating the need to implement VAP care bundles more efficiently and effectively with intense monitoring of compliance with infection control practices and procedures to achieve our goals toward minimizing the incidence of VAP. Acknowledgment The authors thank the participating hospital respondents and the Hospital Infection Society, Mumbai forum, for making this survey possible.
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
936
Letters to the Editor / American Journal of Infection Control 42 (2014) 935-40 100
100
100
93.33
93.33
100
93.33
93.33
92.86 86.67
84.62
90 80 Percentage
70
66.67
61.54
60 50 40
38.46
33.33
30 15.38
20 10
6.67
6.67 0
13.33 6.67 7.14
6.67 0
0
0
% Yes % No
VAP PracƟces Fig 1. Results of the VAP practices survey.
Rohini Kelkar, MD Sanjay Biswas, MD Department of Microbiology Tata Memorial Hospital Mumbai, India
References 1. Coffin SE, Klompas M, Classe D, Arias KM, Podgorny K, Anderson DJ, et al. SHEA/ IDSA practice recommendation: strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(Suppl 1):30-40. 2. American Thoracic Society and Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388-416. 3. Tablan OC, Anderson LJ, Besser R, Bridges C, Haijeh R. Guidelines for preventing ventilator-associated pneumoniad2003. Morb Mortal Recomm Rep 2004; 55(RR-03):1-36. 4. Hawe CS, Ellis KS, Cairns CJ, Longmate A. Reduction of ventilator-associated pneumonia: active versus passive guideline implementation. Intensive Care Med 2009;35:1180-6. 5. Blamoun J, Alfakir M, Rella ME, Wojcik JM, Solis RA, Khan AM, et al. Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit. Am J Infect Control 2009;37: 172-5. 6. Health Protection Surveillance Centre. Guidelines for the prevention of ventilatorassociated pneumonia in adults in Ireland SARI working group. Available from: http://www.hpsc.ie/hpsc/A-Z/MicrobiologyAntimicrobialResistance/Infection ControlandHAI/Guidelines/File, 12530,en.pdf. Accessed September 1, 2013. 7. Hess DR, Kallstrom TJ, Mottram CD, Myers TR, Sorenson HM, Vines DL, American Association for Respiratory Care. Care of the ventilator circuit and its relation to ventilator-associated pneumonia. Respir Care 2003;48:869-79. 8. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a metaanalysis. Am J Med 2005;118:11-8. 9. Staudinger T, Bojic A, Holzinger U, Meyer B, Rohwer M, Mallner F, et al. Continuous lateral rotation therapy to prevent ventilator-associated pneumonia. Crit Care Med 2010;38:486-90. 10. Hidron A, Edwards J, Patel J, Horan TC, Sievert DM, Pollock DA, et al. Antimicrobial-resistant pathogens associated with health careeassociated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control and Hosp Epidemiol 2008;29:996-1011. 11. Juneja D, Singh O, Javeri Y, Arora V, Dang R, Kaushal A. Prevention and management of ventilator-associated pneumonia: a survey on current practices by intensivists practicing in the Indian subcontinent. Indian J Anaesth 2011;55: 122-8. Conflict of interest: None to report.
Vivek Bhat, MD* Advanced Centre for Treatment, Research, and Education in Cancer Department of Microbiology Tata Memorial Centre Navi Mumbai, India
Gita Natarajan, MD King Edward VII Memorial Hospital and Department of Microbiology Seth Gordhandas Sunderdas Medical College Mumbai, India * Address correspondence to Vivek Bhat, MD, Advanced Center for Treatment, Research, and Education in Cancer, Tata Memorial Centre, Navi Mumbai, India. E-mail address: [email protected] (V. Bhat). http://dx.doi.org/10.1016/j.ajic.2014.05.008
A carbapenem-resistant Klebsiella pneumoniae outbreak following bronchoscopy To the Editor: Carbapenemase-producing strains of Enterobacteriaceae are spreading worldwide, increasing the problem of antimicrobial resistance for clinical and public health.1 Here we report an outbreak of carbapenem-resistant Klebsiella pneumonia (CRKP) in an intensive care unit of a German mediumsized hospital that specializes in treating patients after cardiothoracic surgery. Altogether, 8 patients with CRKP producing an oxacillinase (OXA)-48 carbapenemase were identified between May 22, 2013, and June 30, 2013.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Letters to the Editor
Ventilator-associated pneumonia: Survey of infection control practices in intensive care units of 15 tertiary care hospitals in Mumbai To the Editor: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in patients hospitalized in intensive care units (ICUs). Meticulous implementation of infection control measures is a key component for reducing the incidence of VAP. The Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Association for the Profession of Infection Control and Epidemiology, and Centers for Disease Control and Prevention provide guidelines1-3 that comprehensively review the infection control measures for VAP prevention and provide evidence-based recommendations. Studies have shown that the efficient implementation of VAP care bundles decreases the incidence of VAP4,5 and significantly improves outcomes. But although clear recommendations are now available for many components of these bundles (eg, semirecumbent patient positioning), there remain controversies over certain issues (eg, selective digestive tract decontamination). We conducted a survey to determine the VAP policies and practices in various Mumbai hospital ICUs and to compare them for uniformity and differences. A prestructured questionnaire designed to cover the important VAP prevention practices and procedures were circulated to participating hospitals in Mumbai. Respondents included 15 multispecialty tertiary care hospitals. The results of the survey are shown in Figure 1. Other relevant findings included the following. Closed suction systems were used by two-thirds of the respondents; 53.3% reported changing the suction system when it was soiled, 26.67% reported changing the system every 48 hours, and 13.3% reported changing the system every 24 hours. Sixty percent of respondents reported changing the ventilator circuit when it was soiled, 20% reported changing it at 48 hours, and 13.3% reported changing it at 7 days. Heat moisture exchanger humidifiers were used by all respondents; approximately 20% of respondents changed the humidifier at 24 hours, 53.33% did so at 48 hours and 13.33% did so after 72 hours. The important components of ventilator patient care aimed at reducing infection include preventing inspiration of oropharyngeal secretions, preventing contamination of equipment, preventing
colonization of the aerodigestive tract, implementating the VAP care bundle, maintaining meticulous practice, and consistently reinforcing general infection control practices.6 The points covered in this survey were intended to address the aforementioned aspects, which play major roles in reducing the incidence of VAP. One major discrepancy in practice noted in our survey was related to suctioning practices. The effect of closed suction systems on the incidence of VAP remains a matter of debate, with studies reporting inconsistent results. Reductions in colonization may be better achieved by the use of closed suction systems, which also permit continuous ventilation and is safer in view of the much lower risk of aerosolization and is recommended by the American Association for Respiratory Care.7 Another important step in preventing aspiration in ventilated patients is removing subglottic secretions that may accumulate above the endotracheal tube cuff. In patients expected to be ventilated for more than 72 hours, the use of a specialized endotracheal tube with an inbuilt system for subglottic suction to remove oropharyngeal secretions was effective in reducing earlyonset VAP, as demonstrated in a meta-analysis,8 and thus is recommended. The use of kinetic (ie, continuous lateral rotation) beds, although shown to be effective9 in reducing VAP, is limited by safety and cost concerns, as evidenced by its use in <15% of the settings in our survey. VAP practices have been reviewed in various surveys worldwide. Although most of these surveys agree on general principles, there are some differences with respect to prevalent practices and their compliance. Whereas the Centers for Disease Control and Prevention’s National Healthcare Safety Network 2006-2007 summary data10 identify Staphylococcus aureus (24.4%) as the organism most commonly implicated in VAP, followed by Pseudomonas aeruginosa (16.3%), Enterobacter spp (8.4%), Acinetobacter baumannii (8.4%), and Klebsiella pneumoniae (7.5%) were commonly implicated in VAPs, Pseudomonas and Acinetobacter, followed by Staphylococcus, were the common organisms reported in a survey from the Indian subcontinent.11 Our study showed that the common organisms in our setting are Acinetobacter spp, followed by K pneumoniae and P aeruginosa. Our data show a wide variation in VAP rates, ranging from 2.2 to 47 per 1000 ventilator-days, indicating the need to implement VAP care bundles more efficiently and effectively with intense monitoring of compliance with infection control practices and procedures to achieve our goals toward minimizing the incidence of VAP. Acknowledgment The authors thank the participating hospital respondents and the Hospital Infection Society, Mumbai forum, for making this survey possible.
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
936
Letters to the Editor / American Journal of Infection Control 42 (2014) 935-40 100
100
100
93.33
93.33
100
93.33
93.33
92.86 86.67
84.62
90 80 Percentage
70
66.67
61.54
60 50 40
38.46
33.33
30 15.38
20 10
6.67
6.67 0
13.33 6.67 7.14
6.67 0
0
0
% Yes % No
VAP PracƟces Fig 1. Results of the VAP practices survey.
Rohini Kelkar, MD Sanjay Biswas, MD Department of Microbiology Tata Memorial Hospital Mumbai, India
References 1. Coffin SE, Klompas M, Classe D, Arias KM, Podgorny K, Anderson DJ, et al. SHEA/ IDSA practice recommendation: strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(Suppl 1):30-40. 2. American Thoracic Society and Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388-416. 3. Tablan OC, Anderson LJ, Besser R, Bridges C, Haijeh R. Guidelines for preventing ventilator-associated pneumoniad2003. Morb Mortal Recomm Rep 2004; 55(RR-03):1-36. 4. Hawe CS, Ellis KS, Cairns CJ, Longmate A. Reduction of ventilator-associated pneumonia: active versus passive guideline implementation. Intensive Care Med 2009;35:1180-6. 5. Blamoun J, Alfakir M, Rella ME, Wojcik JM, Solis RA, Khan AM, et al. Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit. Am J Infect Control 2009;37: 172-5. 6. Health Protection Surveillance Centre. Guidelines for the prevention of ventilatorassociated pneumonia in adults in Ireland SARI working group. Available from: http://www.hpsc.ie/hpsc/A-Z/MicrobiologyAntimicrobialResistance/Infection ControlandHAI/Guidelines/File, 12530,en.pdf. Accessed September 1, 2013. 7. Hess DR, Kallstrom TJ, Mottram CD, Myers TR, Sorenson HM, Vines DL, American Association for Respiratory Care. Care of the ventilator circuit and its relation to ventilator-associated pneumonia. Respir Care 2003;48:869-79. 8. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a metaanalysis. Am J Med 2005;118:11-8. 9. Staudinger T, Bojic A, Holzinger U, Meyer B, Rohwer M, Mallner F, et al. Continuous lateral rotation therapy to prevent ventilator-associated pneumonia. Crit Care Med 2010;38:486-90. 10. Hidron A, Edwards J, Patel J, Horan TC, Sievert DM, Pollock DA, et al. Antimicrobial-resistant pathogens associated with health careeassociated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control and Hosp Epidemiol 2008;29:996-1011. 11. Juneja D, Singh O, Javeri Y, Arora V, Dang R, Kaushal A. Prevention and management of ventilator-associated pneumonia: a survey on current practices by intensivists practicing in the Indian subcontinent. Indian J Anaesth 2011;55: 122-8. Conflict of interest: None to report.
Vivek Bhat, MD* Advanced Centre for Treatment, Research, and Education in Cancer Department of Microbiology Tata Memorial Centre Navi Mumbai, India
Gita Natarajan, MD King Edward VII Memorial Hospital and Department of Microbiology Seth Gordhandas Sunderdas Medical College Mumbai, India * Address correspondence to Vivek Bhat, MD, Advanced Center for Treatment, Research, and Education in Cancer, Tata Memorial Centre, Navi Mumbai, India. E-mail address: [email protected] (V. Bhat). http://dx.doi.org/10.1016/j.ajic.2014.05.008
A carbapenem-resistant Klebsiella pneumoniae outbreak following bronchoscopy To the Editor: Carbapenemase-producing strains of Enterobacteriaceae are spreading worldwide, increasing the problem of antimicrobial resistance for clinical and public health.1 Here we report an outbreak of carbapenem-resistant Klebsiella pneumonia (CRKP) in an intensive care unit of a German mediumsized hospital that specializes in treating patients after cardiothoracic surgery. Altogether, 8 patients with CRKP producing an oxacillinase (OXA)-48 carbapenemase were identified between May 22, 2013, and June 30, 2013.