by Dr. Marion A. Kwek

1. PREVENTION & CONTROL OF
COMMON HAIS: THE BUNDLE
APPROACH ON HAP/VAP
Marion Aurellado Kwek, MD, FPCP, FPSMID
17 Feb 2016

2. OUTLINE
 Definitions
 Pathophysiology of Nosocomial
Pneumonia
 Risk Factors
 Prevention
 Prevention Bundles

3. DISCLOSURE
 Received honoraria for lectures from Merck
Sharp Dohme

4. INTRODUCTION
 Nosocomial pneumonia pneumonia
acquired while in a hospital
 From the Latin word nosocomium:
“hospital”
 Classically divided into:
 Hospital-acquired pneumonia (HAP)
 Ventilator-associated pneumonia (VAP)
 Recently has also been applied to health
care–associated pneumonia (HCAP)
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases 8th Ed. 2015

5. INTRODUCTION
 HAP is the leading cause of death among
HAIs, with estimates of HAP-associated
mortality ranging from 20 to 50%
 Systematic review of published studies
found attributable mortality rate of 13%
for VAP
Melsen et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of
individual patient data from randomised prevention studies. Lancet Infect Dis. 2013 Aug;13(8):665-71

6. INTRODUCTION
 Most cases of HAP occur outside of intensive care
units.
 Highest risk for HAP is in patients on
mechanical ventilation (ie, VAP)
 Steady decline in reported VAP rates in the US,
VAP from 0.0 to 4.4 per 1000 ventilator days
depending on the patient care location in 2012
2012 NHSN Annual Report

7. DEFINITIONS

8. DEFINITIONS (CLINICAL)
 Hospital-acquired (or nosocomial) pneumonia
(HAP)
 Pneumonia that occurs 48 hours or more
after admission
 Not incubating at the time of admission
 Ventilator-associated pneumonia (VAP)
 Develops more than 48 to 72 hours after
intubation.
 Healthcare-associated pneumonia (HCAP)
 Pneumonia in a nonhospitalized patient
 With extensive healthcare contact
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia.
Am J Respir Crit Care Med Vol 171. pp 388–416, 2005

9. DEFINITIONS (CLINICAL)
 Healthcare Contact
 IVT, wound care, or IV chemotx within the
past 30 days
 Residence in a nursing home or other long-
term care facility
 Hospitalization in an acute care hospital
for two or more days within the prior 90
days
 Attendance at a hospital or hemodialysis
clinic within the prior 30 days
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia.
Am J Respir Crit Care Med Vol 171. pp 388–416, 2005

10. http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_by_Organ_System/
Lower/Upper_Respiratory/Hospital-Acquired_Pneumonia_(HAP)/

11. DEFINITIONS (SURVEILLANCE)
 To be discussed on 19 Feb 2016
 Surveillance of HAI (Didactic) - Dominga
C. Gomez, RN and Dr. Dess Roman
 Clinical diagnosis ≠ Surveillance Criteria

12. PATHOPHYSIOLOGY

13. PATHOPHYSIOLOGY
 Histologic hallmark of VAP is heterogeneity
 Lesions vary significantly in age and
severity
 Dependent areas > nondependent areas
 Different organisms can be cultured from
different lung segments of the same patient
in 25% to 37% of cases
 Cultures of histologically benign–appearing
lung segments are often positive.
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases 8th Ed. 2015

14. PATHOPHYSIOLOGY
 Ventilated patients prone to repeated
microaspirations around the ET cuff
 Microbiologic, structural, and humoral
factors combine to increase the risk of
pneumonia in critically ill patients
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases 8th Ed. 2015

15. PATHOPHYSIOLOGY
 Flora of the oral tract
rapidly shifts from
community respiratory
organisms (Strep,
Haemophilus) toward
“hospital-associated”
pathogens (S. aureus,
Enterobacteriaceae,
Pseudomonas, &
Acinetobacter sp.)

16. PATHOPHYSIOLOGY
 Likelihood of
organisms being drug
resistant steadily
increases with time in
a hospital, exposure to
antimicrobials, and
severity of illness.

17. PATHOPHYSIOLOGY
 OGT/NGT disrupt lower esophageal
sphincter + increase risk of aspiration of
gastric contents
 ET disrupts normal ciliary clearance of
bronchial secretions + impairs patients’
capacity to cough.
 Secretions pool above ET cuff and
intermittently seep around folds in the cuff,
particularly if the cuff is underinflated or if it
shifts during patient movement or
repositioning.

19. PATHOPHYSIOLOGY
 Biofilm begins to form both inside and
outside the endotracheal tube within a day of
placement and serves as a bacterial reservoir
within the trachea and oropharynx.
 Suctioning or instillation of aerosols through
the endotracheal tube can mobilize and
embolize bacteria from the biofilm into the
lungs.

20. Photo from slideshare

21. PATHOPHYSIOLOGY
 Critical illness, poor nutrition, and
immobilization may increase patients’
susceptibility to infection.
 These factors interact and reinforce with one
another to enhance the risk of
microaspiration and the likelihood that
pulmonary parenchymal colonization will
lead to invasive infection.

22. Lifted from Oliveira et al. Prevention of Ventilator associated pneumonia 2014

23. RISK FACTORS

24. RISK FACTORS
Factors that enhance risk of
aspiration increase the likelihood
of infection!!!

25. RISK FACTORS
Factors Examples
Mechanical factors •Emergency intubation,
reintubation, duration of
intubation
•Supine positioning
•Enteral feeding with OGT/NGT
•Use of paralytic agents
•Underinflation of ET cuff
Mental Status •CNS disease
•Level of consciousness
•Level of sedation

26. RISK FACTORS
Factors Examples
Bacterial bioburden
in the upper
respiratory and
orogastric tracts
•Duration of hospitalization
•Nasogastric intubation
•Prolonged antibiotic
exposures
•Use of PPIs or other gastric
acid suppressants
Increased handling
or breaking of the
ventilator circuit
Inhaled β-agonist therapy

27. RISK FACTORS
Factors Examples
Patient factors •Age > 70 yrs
•Preexisting lung disease
•Severity of illness
•Surgical patients, (burn and
trauma) higher VAP rates than
medical patients
Others •Intensive care staffing levels
•Transportation out of ICU for
diagnostic imaging or procedures

28. PREVENTION
 Most prevention strategies are designed to
decrease volume of regurgitant secretions or
decrease the bacterial burden in and around
oropharynx and ET, or both
 Many interventions lower VAP rates, but few
improve concrete outcomes such as duration of
ventilation, ICU length of stay, or hospital
mortality

30. PREVENTION BUNDLES

31. PREVENTION BUNDLES
 Grouping multiple interventions together into
VAP prevention “bundles” may enhance their
effectiveness by exploiting synergies between
interventions or by enhancing their visibility,
immediacy, and hence performance by frontline
providers.
 VAP prevention bundles have become a standard
of care in most hospitals

32. Recommendation Rationale Intervention Quality of
evidence
Basic practices Good evidence
that intervention
Decreases
average duration
of
MV, length of
stay, mortality,
and/or costs;
benefits
likely outweigh
risks
Use NIPPV in selected
populations
Manage pxs w/o sedation
whenever possible
Interrupt sedation daily
Assess readiness to
extubate daily
Perform spontaneous
breathing trials w/
sedatives turned off
High
Moderate
High
High
High
Summary of Recommendations for Preventing Ventilator-Associated Pneumonia
(VAP) in Adult Patients. SHEA/IDSA 2014

33. Recommendation Rationale Intervention Quality of
evidence
Basic practices Good evidence
that intervention
Decreases
average duration
of
MV, length of
stay, mortality,
and/or costs;
benefits
likely outweigh
risks
Facilitate early mobility
Utilize ET with
subglottic secretion
drainage ports for
patients expected to
require greater
than 48 or 72 hrs of MV
Change the ventilator
circuit only if visibly
soiled or
malfunctioning
Elevate the head of the
bed to 30–45
Moderate
Moderate
High
Low
Summary of Recommendations for Preventing Ventilator-Associated Pneumonia
(VAP) in Adult Patients. SHEA/IDSA 2014

35. Recommendation Rationale Intervention Quality
evidence
Special approaches Good evidence
that the
intervention
improves
outcomes but
insufficient
data available on
possible risks
May lower VAP
rates but
insufficient
data to determine
impact on
duration
of mechanical
ventilation,
length
of stay, or
mortality
Selective oral or
digestive
decontamination
Regular oral care with
chlorhexidine
Prophylactic probiotics
Ultrathin polyurethane
endotracheal tube cuffs
Automated control of ET
cuff pressure
Saline instillation before
tracheal suctioning
Mechanical tooth
brushing
High
Moderate
Moderate
Low
Low
Low
Low
Summary of Recommendations for Preventing Ventilator-Associated Pneumonia
(VAP) in Adult Patients. SHEA/IDSA 2014

36. Recommendation Rationale Intervention Quality
evidence
Generally not
recommended
Lowers VAP
rates but ample
data suggest
no impact on
duration of
mechanical
ventilation,
length of stay,
or mortality
No impact on
VAP rates,
average duration
of mechanical
ventilation,
length
of stay, or
mortality
Silver-coated Ets
Kinetic beds
Prone positioning
Moderate
Moderate
Moderate
Summary of Recommendations for Preventing Ventilator-Associated Pneumonia
(VAP) in Adult Patients. SHEA/IDSA 2014

37. Recommendation Rationale Intervention Quality
evidence
No
recommendation
No impact on
VAP rates or
other patient
outcomes, unclear
impact on
costs
Closed/in-line ET
suctioning
Moderate
Summary of Recommendations for Preventing Ventilator-Associated Pneumonia
(VAP) in Adult Patients. SHEA/IDSA 2014

38. PREVENTION BUNDLES
 Involve implementation of various measures in
an attempt to reduce the incidence of VAP among
at risk patients
 Measures often include educational programs,
technical measures, surveillance, and feedback
 Practical way to enhance care

39. PREVENTION BUNDLES: EVIDENCE
 Eight practices: hand hygiene, glove and gown
compliance, elevation of the head of the bed, oral
care with chlorhexidine, maintaining an ET cuff
pressure >20 cm H20, orogastric rather than
nasogastric feeding tubes, avoiding gastric
overdistention, and eliminating nonessential
tracheal suctioning
 Rate of VAP decreased from 23 to 13 VAP
episodes per 1000 ventilator-days
 No differences in total duration of mechanical
ventilation or the ICU and hospital death rates.
Bouadma L, et al. Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia
in a medical intensive care unit. Clin Infect Dis. 2010;51(10):1115.

40. PREVENTION BUNDLES: EVIDENCE
 Five interventions: semirecumbent position,
stress ulcer prophylaxis, DVT prophylaxis,
adjustment of sedation, and daily assessment for
extubation
 Tested in 112 ICUs with 550,800 ventilator-days
 VAP rate from a median of 5.5 cases per 1000
ventilator-days at baseline to a median of 0 cases
at 16 to 18 months after implementation
Berenholtz SM et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.
Infect Control Hosp Epidemiol. 2011;32(4):305.

41. PREVENTION BUNDLES
 Wide variability in their components and
definitions for adherence
 No consensus about which care processes to
include

42. SUMMARY
 Definitions
 Pathophysiology
 Risk Factors
 Prevention
 Prevention Bundles

43. CHALLENGE
 Formulate bundles
 Implement
 Monitor
 RCTs