This document discusses strategies for preventing pneumonia in the ICU. It begins by defining hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), noting they are common ICU infections associated with high mortality. Risk factors and pathways for pneumonia are described. Strategies with probable effectiveness discussed include hand hygiene, vaccinations, isolation of resistant organisms, nutritional support like early enteral feeding, stress ulcer prophylaxis, and semi-recumbent positioning. Unproven strategies under investigation are also outlined. The document stresses bundles of interventions work better than individual measures to reduce ICU-acquired pneumonia.

1. Prevention of
Pneumonia in
ICU
Dr/ Sami El-Dahdouh
Associate Prof. of pulmonary and critical care
Menoufia Faculty of Medicine

2.  HAP is defined as pneumonia that occurs
48 hours or more after admission, which
was not present nor incubating at the time
of admission .
 HAP accounts for 10-25% of all ICU infections
and for more than 50% of the antibiotics
prescribed .
 Mortality rate for HAP may be as high as 30 -
70%,

3. *VAP....... 25% of all nosocomial
infections in ICU.
*VAP ........ 20-50% morbidity and
mortality.
*VAP...... is a preventable disease.

4. Pneumonia to occur
Predis
posing
factors
Source
of
infection
Organism
entry
into
lung

5. Predisposing
Factors
Virulent
organism
Decreased general
immunity
Defect in
Clearing
mechanisms
Defective in clearing mechanism e.g.
- cough or gag reflex lost (Coma, paralysis,
addiction).
- obstructions (FB, tumors).
- pulmonary edema.
- mucosal injury aspiration, smoking.

6. Source of
infection
Person to Person
S. pumonia, TB,
Mycoplasma and viral
Environment
Leiogenalla (water)
Pstacossis(bird)
Anthrax (soil)
Healthcare devices (contaminated nebulizers, ventilation
circuits or humidifiers)
The environment (air, water, equipment, and fomites),
Commonly the transfer of microorganisms between the
patient and staff.
Stomach, sinuses, dental plaque and oropharynx
(colonization),

7. Organism entry
Into lung
Inhalation
OR
Aspiration
Blood spread
Direct spread
OR
Colonization
1. Aspiration of oropharyngeal pathogens.
2. Inhalation of pathogens from contaminated aerosols,
3. Hematogenous spread from infected intravascular
catheters ,
4. Bacterial translocation from the gastrointestinal tract
lumen are quite rare.

9. Regimens Of
Probable Efficacy
For Specific
Indications
Regimens Of
Probable Efficacy
used widely in some
clinical settings
Regimens Of
Unproven Value
Used On Limited
Investigational Or
Clinical Basis
Unproven
Regimens Still
Being Evaluated
Prevention of pneumonia

10.  Vaccinations against s pneumonia and
influenza virus.
 Hand washing between patient contact.
 Isolations patients with highly resistant
organisms such as MRSA.
Regimens Of Probable Efficacy
For Specific Indications

11. A) Nutritional support.
1-Entral feeding via feeding jejenostomy better than
TPN and lower incidence of infections as entral
stimulate intestinal mucosa preventing bacterial
translocation.
2-use of orogastric rather than nasogastric can
decrease the incidence of nosocomial sinusitis which
lead to HAP.
3- risk of aspiration increase with large bore feeding
tube and with bolus feedings than with the use
smalled tubes of continuous feeding methods.
Regimens With Probable Effectiveness
Used Widely In Some Clinical Settings

12. B) Regimens for intestinal bleeding prophylaxis
sucralfate (doesn't increase gastric PH) when
compared with antacid ( increase both gastric PH and
volume increase risk of aspiration) or with H -2
Antagonist(decrease gastric PH enhancing bacterial
translocation).
C) Putting The Patients In The Semi Recumbent
Position appear to reduce risk of aspiration.
D) Handling Of Respiratory Equipments:
1- Suction Catheter single use non sterile disposal
gloves should be worn for suction, And change suction
catheter between patients and after each use.

13. 2- Suction Bottles single use disposal or reusable
wash with detergent, dry and disinfect them with
autoclave or in washing machine.
3- Breathing Circuits ventilator circuit are rapidly
colonized with bacteria and condensate within
these circuit can have high bacterial counts and
aspiration of condensate may play a role in
development of nosocomial pneumonia, so
change every 48 hs, periodic drain breathing
condensate.
4- Nebulizers change or reprocess devices
between patients by using sterilization or high
level of disinfection or use single disposal item.

15. 5- Humidifiers clean and sterilize devices between
patients and fill with sterile water which must be
changed every 24 hs or sooner, if necessary single
use disposal humidifiers are available.
F) Subglottic Secretion Drainage:
Secretions pooled above
the endo tracheal tube cuff
represent reservoir
of the colonizing bacteria
thus removing this pool
may decrease incidence
of VAP.

16. ETT cuff inflation via minimal leak
technique to 20-25cmH2O(minimal
occlusive pressure).

17. A) Selective Digestive Decontamination (SDD)
SDD involve use of topical oral and intestinal
antibiotics, often with systemic antibiotic added for
the first few days of the regimens with the goal being
the elimination of all potential pathogens from GIT.
Sterilization of endogenous bacterial sources may
avoid infection, of debate as emergence of antibiotic
resistant organisms.
B) Topical antibiotic on the lower respiratory
tract. decrease incidence of pneumonia.
Regimens Of Unproven Value Used On
Limited Investigational Or Clinical Basis

18. A) Manipulations of endogenous source of
bacteria.
Unproven Regimens Still Being
Evaluated

19. The endotrachael tube can harbor the growth of
large no of bacteria along its inner surface, and the
bacteria at this site will persist in the airway free from
the effect of antibiotic and host defenses.
The development of new biomaterial for tubes could
lead to elimination of a tracheal tube biofilm and
eradication of reservoir of bacteria in the airways.

20. B) Biological response modifiers
These substances are immunomodulator have
the ability to up regulate or down regulate host
defense mechanisms. e.g..
1) Antilipopolysaccride antibodies(E5 and
HA-IA)
2) antibodies toward TNF, IN 1, PAF.

21. * Bundles are group of intervention related to a
disease that when instutes together give better
outcomes than when done individually.
* Provide a mechanism to enhance teamwork and
enhance outcome.
* The guideline become as road map to enhance
outcome.

22. Elevation of the bed between 30-45 degree
at all time (unless contraindicated).
Deep venous thrombosis (DVT)
prophylaxis (unless contraindicated).
Peptic ulcer prophylaxis
sedation interruption
Weaning protocol
Oral care

23. * Please remember to elevate the HOB>30 degree , and
raise knees for all ventilated patients unless
contraindicated .
*Elevation of HOB has been correlated with reduction in the
rate of the ventilator associated pneumonia.
Drakulovi Lancet, 1999

24. *As elevation of head of bed may contribute to
venous stasis and DVT.
*The risk of venous thromboembolism is reduced
if prophylaxis is consistently applied.
*A clinical practice guideline recommends DVT
prophylaxis for patients admitted to the ICU.
(Geerts, Chest,2004)

25. *Stress ulceration are the most common cause of
gastrointestinal bleeding in intensive care unit
patients .
*This predisposed to aspiration and VAP .
*Thus applying PUD prophylaxis is a necessary
intervention.

26. Sedation in ICU has the benefit of reducing
psychological problems to the patients .However
heavy sedation is harmful and predispose to VAP
by :
1-Inhibiting coughing.
2-Inhibiting mobilization.
3-Decreasing immune function.
4-Promoting aspiration.
5-Prolongs time on ventilator.

27. 1-Awake and cooperative patient.
2-Cough , swallowing reflexes intact.
3-Add analgesia to the protocol .
4-Intermittent rather than continuous sedation.
5-Sedation vacation (sedation interruption).

28. Application:
 Hold sedation until patient is alert or can follow commands at least
once a day.
 *After sedation interruption restart sedation at a fraction of the prior
dose (1/2 or 3/4).
 *Kress et al .,conducted a randomized controlled trial in 128 adults
mechanically ventilated patients receiving continuous infusion of
sedative agents in a medical ICU, daily interruption of sedation
resulted in a highly significant reduction in time spent on mechanical
ventilation, from 7.3 days to 4.9 day (p=0.004).
(Kress, N Engl J Med,2000)

29. * Non-physician driven weaning protocol (by nurses or
respiratory therapists).
* Daily assessment of readiness to wean from ventilator:
 keep TV and pressure low.
 preextubation assessment and worksheet .
(Dries JTrauma,2006)

30. Designed for patients who are intubated
or tracheostomiazed
*Mouth care protocol.
*Brush twice .
*Swab every two hours.
*Chlorhexidine rinse.
*Apply mouth moisturizer.
(Chlebicki, Crit Care Med,2007)

31. Thank you