Ventilator Associated

Pneumonia

CDC defines VAP as a nosocomial infection diagnosed

in patients undergoing MV for at least 48 h

VAP is the second most frequent cause of nosocomial

infection (20% of nosocomial infec- tions) in pediatric
intensive care units (PICU)
Incidence

VAP rates for neonates weighing less than 1000 g

ranged from 2.4 to 8.5 episodes per 1000 ventilator
days.
-National Nosocomial Infections
Surveillance system data from 2004

Other investigators reported rates varying from 12.5 to

52 infections per 1000 ventilator days.
Predisposing Factors

Prematurity
VLBW
MV duration
Pathogenesis
Under normal circumstances
-Anatomic barriers,
-cough reflexes
-Tracheobronchial secretions
- Mucociliary lining
- Cell- mediated and humoral immunity
- Phagocytic system of the alveolar
macro- phages and neutrophils protect the lung
parenchyma from infection.
Microorganisms responsible for VAP can originate
from endogenous or exogenous sources.
 Eleva-tion of the head of the bed may reduce the risk of
aspiration of contaminated oropharyngeal and
gastrointestinal contents in adults.
Reduced tracheal colonization from oropharyngeal
contamination through lateral positioning of infants.
-Aly and colleagues
Studies using rigorous culturing techniques have shown
that oropha- ryngeal colonization plays a more
important role in the development of endogenously
acquired VAP than gastric
 Exogenous Sources-
Caregiver hands
Ventilator circuits
Airway suctioning equipment
Humidifiers, and nebulizers
Microbiology
Gram-positive organisms in the mouth colonize the
trachea and endotracheal tubes within the first 48 hours
of mechanical ventilation.
Gram-negative bacilli begin colonizing the endotracheal
tube and trachea after 48 hours of respiratory support.
 Staphylococcus aureus
Gram-negative organisms -Pseudomonas aeruginosa
Eschericha coli,
Klebsiella pneumoniae,
Enterobacter sp, and
Acinetobacter sp are the most common pathogens
responsible for VAP
Sample Collection
Bronchoalveolar lavage (BAL) and Protected specimen brush (PSB)
is highly specific but invasive and only effective in experienced
hands.
TA are more accessible and easy to use, but they tend to
overdiagnose VAP.
Gauvin et al. concluded that blind BAL with a bacterial index (sum of
the log of all species obtained from BAL) 5 was the most reliable
method for diagnosing VAP.
Unfortunately, bronchoscopic BAL and PSB are not applicable in
neonatology because of the small diameter of the ETT.
Blind-protected BAL appears to be the most reliable sampling
method in the neonates.
Clinical Signs
CDC creteria.
Most prevalent --Changes in the characteristics and
volume of re- spiratory secretions and the appearance
of purulent mucus in TA.
Diagnostic Biomarkers
Procalcitonin
Released in response to bacterial in- fections
[interleukin (IL)-1, IL-6, or TNF-.
Upregulation of PCT is inhibited by interferon (IFN)-, a
cytokine released in response to viral infections
After only 612 h of stimulation PCT blood levels will
increase and once the infection is controlled these
values will descend rapidly.
Cytokines

Proin- flammatory cytokines such as IL-1, IL-6, IL-8, IL-

10, and TNF- have been evaluated in adults as
markers of VAP, with discordant results.
Association bw VAP and IL-1B and IL-8 in BAL. -Conway
Morris
IL-6 capable of differentiating VAP from other causes of
infiltrates. -Ramirez et al
TREM-Triggering receptor expressed on myeloid
cells
Expression of TREM-1 is upregulated after stimulation
with bacterial and fungal products.
Determann et al-did not find differences in plasma
levels.
Horoneko et al-did not find differences in s-TREM
concentrations between patients with VAP and controls.
Srinivasan et al evaluated the role of s-TREM and
plasminogen activation inhibitor-1 (PLA- 1) in the
diagnosis of VAP in a PICU. They reported that elevated
levels of PLA-1 had the strongest association with a
clinical diagnosis of VAP and were the best bio- marker
to differentiate VAP from colonization.
 Few studies (and with disappointing results) on the use
of biomarkers in neonatology have been reported.
Hence, PCT has been extensively employed for the
diagnosis of suspected sepsis.

However, the presence of a normal, physiological surge

in serum PCT 24 h after birth lasting up to 72 h has
precluded its use in the early neonatal period, especially
for the diagnosis of early-onset sepsis.

No study established an association of PCT with

neonatal VAP.
No study correlating plasma interleukin levels and VAP.
 Harwood et al detected GSA(glutathione
sulfonamide) in 75% of TA of ventilated preterm
infants.
GSA showed good sensitivity and specificity for de-
tecting bacterial growth.
Further studies should confirm the valid- ity of this new
biomarker.
Finally, Gram staining studies on TA have also
shown promising results.
Katayama et al recently reported a sensitivity of 82 and
100%, and a specificity of 100 and 82% for Gram-
positive and Gram- negative VAP, respectively, in VLBW
infants.
 Low-birth-weight neonates rarely develop cough,
rhonchi, fever, or wheezing during an episode of
pneumonia, and determining the presence of
pneumonia from radiographs of low-birth-weight
neonates with underlying chronic lung disease can be
difficult.
Treatment
Full course of empiric broad- spectrum antibiotics.
Empiric therapy usually includes an antipseudomonal agent such as
Piperacillin- tazobactam or Ticarcillin-clavulanate that provides
coverage for most gram-negative organisms and some gram pos.

local flora includes extended- spectrum b-lactamase producing

organisms, Carbapenems more appropriate for initial empiric therapy.
Addition of an aminoglycoside is appropriate if bacteremia is
suspected or significant systemic symptoms are present.

Local epidemiology may dictate the use of dedicated gram-positive

coverage for resistant organisms such as methicillin-resistant
Staphylococcus.(MRSA)
 In extensive drug-resistant infections, aerosolized
adminis- tration may be an appropriate route to deliver
antibiotics and reduce systemic toxicity.
Prevention
Positioning
ETT and suction
Hand Washing
Rapid Extubation
Sedation Vacation
SDD ??
Probiotic ??
Positioning
Most adult VAP prevention bundles recommend
elevating the head of a ventilated patients bed to
between 30 and 45
Horizontal lateral position also recommended.
Only 1 underpowered pediatric trial presented in
abstract form has evaluated this intervention and
showed no effect.
Best position to prevent VAP in ventilated neonates is
the head of the bed kept up or a horizontal left or right
lateral position of the neonate needs further study.
 ETT and Suction:
Because most organisms responsible for VAP originate
from the oropharynx of ventilated patients, the CDC
recommends that secretions be cleared from above the
cuff of the endotracheal tube whenever the tube is
repositioned or removed.
CDC suggest the use of ETT with dorsal lumens to
allow drainage of respiratory secretions,
orotracheal instead of nasotracheal intubation,
and a change of ventilators respiratory circuits
only if they are visibly contaminated or do not
work.
 Use of ETT with nano-modified coatings apparently
reduces the incidence of infections in the respiratory
airways.
Published experiences in the neonatal period are
lacking.

Suctioning:
Use of closed versus open endotracheal suc- tion
systems in ventilated neonates. No differences in the
incidence of VAP or mortality between groups were
found.
CDC recommendations do not endorse one system over
the other, and there are no recommendations
addressing the frequency at which closed suctioning
 Avoid routine suction. The depth of suction catheter insertion
should be measured beforehand. Care should be taken to
suction pressure to avoid damaging the respiratory mucosa.

When open tracheal suction method is used:

(a) Use a sterile, single-use suction catheter
(b) Perform hand hygiene before wearing gloves.
It is preferable to use sterile gloves than clean gloves for
endotracheal suction. If clean gloves are used, ensure the
sterility of inserted part of suction catheter is maintained
c) When a suction catheter is blocked by secretions, it is
preferable to discard it and use a new suction catheter.
 Avoid the routine practice of using saline instillation to
loosen sputum for suction. This practice does nothing to
aid the underlying problem of dried and tenacious
secretions but has potential detrimental effects such as
decreasing oxygenation levels and causing
contamination.
Prevent aspiration

Place the ventilated patient in semi-upright position

between 30 and 45 degrees, especially during feeding
and transport, unless there is contraindication.
Verify the gastric tube is in proper position every time
before feeding.
Adjust the rate of tube feeding carefully according to
individuals tolerance to prevent gastric over-distention.
Avoid use of large-bore gastric tube unnecessarily as it
affects the
sphincter closure and increases the risk of regurgitation.
Hand washing:
Routine hand washing is one of the most important
strategies to reduce nosocomial infections.
Systematic use of alcohol- based gels for hand hygiene
by caregivers reduced the rate of VAP in VLBW infants
by 38%.
Rapid Extubation:
Duration of MV appears to be a major risk factor for the
development of VAP in neonates.
Use of noninvasive measures such as NCPAP and nasal
prong ventilation may help to reduce VAP rates.
After extubation, repeat intubation should be avoided
because of the increased risk of VAP associated with
reintubation.

Sedation Vacation: Should be given to reduce

the duration of MV.
 Interrupt or lighten sedations daily at an appropriate time to
assess patients readiness for extubation.

Breathing circuit condensate contamination can also serve as

a mechanism for pathogenesis of VAP. The condensate that
collects in the tubing should be drained away to prevent
aspiration.

Use sterile water to fill the humidifier of ventilator. It is an

acceptable option to set up a closed water-refilling system to
minimize manipulation of the humidifier system.
Use of Histamine 2 Receptor
Antagonists or Antacids
use of histamine 2 receptor antagonists or antacids is
believed to reduce VAP.
However, no differences in the incidence of VAP were
found when comparing.
No published experience in the neonatal period.
However, necrotizing enterocolitis and gram- negative
bacteremia have been associated with H 2 blocker use
in neonates.
Selective Digestive Tract Decontamination

RCT-conflicting results
Non RCT-NICU patients received oral polymixin E,
tobramycin, and nystatin correctly (during the first 5
days) or incorrectly (after 5 days).
Results revealed that correct selective decolonization
had a pro- tective effect toward nosocomial infections of
an intestinal origin. However, a separate analysis of the
impact on respiratory infections alone was not
performed.
Oral Hygiene
Chlorhexidine gluconate is not approved for neonates younger
than 2 months, and there are little neonatal data to evaluate oral
hygiene and VAP risk.

CDC makes no recommendation for the use of an oral

chlorhexidine rinse for the prevention of VAP in ill patients.

Until further data are available, it seems prudent to follow the

recommendation of the American Dental Association to wipe the
gums and keep the mouth clean after feedings and when needed.

Separate suctioning equipment should be used for tracheal and

oral secretions.
Probiotic
Recent meta-analysis of 7 randomized controlled trials
conducted in adult populations concluded that
probiotics showed no beneficial effect.