Hostname: page-component-78c5997874-8bhkd Total loading time: 0 Render date: 2024-11-02T19:22:00.381Z Has data issue: false hasContentIssue false
  • English
  • Français

Diagnosis, management and prevention of ventilator-associated pneumonia in the UK

Published online by Cambridge University Press:  01 November 2007

J. Hunter ,
S. Annadurai  and
M. Rothwell
J. Hunter*
Affiliation:
Macclesfield District General Hospital, Department of Anaesthetics and Intensive Care, Macclesfield, UK
S. Annadurai
Affiliation:
Alder Hay Hospital, Department of Anaesthetics, West Derby, Liverpool, UK
M. Rothwell
Affiliation:
Macclesfield District General Hospital, Department of Anaesthetics and Intensive Care, Macclesfield, UK
*
Correspondence to: John Hunter, Consultant in Anaesthetics and Intensive Care, Macclesfield District General Hospital, Victoria Road, Macclesfield SK10 3BL, UK. E-mail: [email protected]; Tel: +44 1625 661307; Fax: +44 1625 663209
Get access

Summary

Background and objective

Ventilator-associated pneumonia is a nosocomial infection that occurs in patients receiving mechanical ventilation for >48 h. Many aspects of its diagnosis, treatment and management are controversial. We used a postal questionnaire to survey current practice within the UK.

Methods

Questionnaire study of 207 general intensive care units in the UK.

Results

The response rate was 77.3%. Regarding diagnosis, 30% of units obtained specimens from the lungs invasively, while the remainder relied on tracheal aspirates. In only 28.2% of units using tracheal aspirates were results reported in a quantitative manner. A clinical suspicion of ventilator-associated pneumonia would lead to the administration of empirical antibiotic therapy in the majority of units (77.2%), opinion being almost equally divided on whether this should be mono (49.1%) or combination therapy (50.9%). Although most units received regular microbiology feedback (90.5%), the involvement of a microbiologist in the antibiotic decision-making process was variable. Antibiotics were continued for a median of 7 days (inter-quartile range 5–8.5, range 2–14 days). Compliance with the principal methods of ventilator-associated pneumonia prevention was good.

Conclusion

There is widespread variation in the methods used for the diagnosis of ventilator-associated pneumonia within the UK. The majority of units rely on non-quantitative analysis of tracheal aspirates. This technique has a high percentage of false-positives, and suggests widespread over utilization of antibiotics. However, most agree that antibiotics should be given empirically when there is a clinical suspicion of ventilator-associated pneumonia. The widespread introduction of ‘ventilator bundles’ appears to have ensured that most units actively take measures to prevent ventilator-associated pneumonia.

Keywords

PNEUMONIAVENTILATOR ASSOCIATEDCRITICAL CAREPREVENTION AND CONTROLDIAGNOSISQUESTIONNAIRE
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 24 , Issue 11 , November 2007 , pp. 971 - 977
Copyright
Copyright © European Society of Anaesthesiology 2007

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Vincent, JL, Bihari, DJ, Suter, PM et al. . The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) study. JAMA 1995; 274: 639–644.CrossRefGoogle ScholarPubMed
2.Heyland, DK, Cook, DJ, Griffith, L et al. . The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med 1999; 159: 1249–1256.CrossRefGoogle ScholarPubMed
3.Fagon, JY, Chastre, AJ, Hance, AJ et al. . Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 1993; 94: 281–288.CrossRefGoogle ScholarPubMed
4.Celis, R, Torres, A, Gatell, JM, Almela, M, Rodriguez-Roisin, R, Agusti-Vidal, A. Nosocomial pneumonia. A mulitivariate analysis of risk and prognosis. Chest 1988; 93: 318–324.CrossRefGoogle Scholar
5.Chastre, J, Fagon, JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002; 165: 867–903.CrossRefGoogle ScholarPubMed
6.Haley, RW, Hooton, TM, Culver, TH et al. . Nosocomial infection in US hospitals 1975–76. Estimated frequency by selected characteristics of patients. Am J Med 1981; 70: 947–959.CrossRefGoogle Scholar
7.Chevret, S, Hemmer, M, Carlet, J et al. . Incidence and risk factors of pneumonia acquired in intensive care units. Results from a multi-centre prospective study on 996 patients. European Cooperative Group on Nosocomial Pneumonia. Intensive Care Med 1993; 19: 256–264.CrossRefGoogle Scholar
8.Shorr, AF, Kollef, MH. Ventilator-associated pneumonia. Insights from recent trials. Chest 2005; 128: 583S–591S.CrossRefGoogle Scholar
9.Sierra, R, Benitez, E, Leon, C, Rello, J. Prevention and diagnosis of ventilator-associated pneumonia: a survey on current practices in Southern Spanish ICU’s. Chest 2005; 128: 1667–1673.CrossRefGoogle Scholar
10.Rello, J, Lorente, C, Bodi, M, Diaz, E, Ricart, M, Kollef, MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002; 122: 656–661.CrossRefGoogle Scholar
11.Kollef, MH. The prevention of ventilator-associated pneumonia. N Engl J Med 1999; 340: 627–634.CrossRefGoogle ScholarPubMed
12.Hubmayr, RD, Burchardi, H, Elliot, M et al. . American Thoracic Society Assembly on Critical Care; European Respiratory Society; European Society of Intensive Care Medicine; Societe de Reanimation de Langue Francaise. Statement of the 4th International Consensus Conference in Critical Care on ICU-Acquired Pneumonia--Chicago, Illinois, May 2002. Intensive Care Med 2002; 28: 1521–1536.CrossRefGoogle ScholarPubMed
13.CMA Medical Data. Directory of Operating Theatres and Departments of Surgery. Cambridge: CMA Medical Data, 2003.Google Scholar
14.Wunderink, RG. Radiologic diagnosis of ventilator-associated pneumonia. Chest 2000; 117: 188S–190S.CrossRefGoogle ScholarPubMed
15.Meduri, GU, Mauldin, GL, Wunderink, RG et al. . Causes of fever and pulmonary densities in patients with clinical manifestations of ventilator-associated pneumonia. Chest 1994; 106: 221–235.CrossRefGoogle ScholarPubMed
16.Jourdain, B, Novara, A, Joly-Guillou, ML et al. . Role of quantitative cultures of endotracheal aspirates in the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 1995; 152: 241–246.CrossRefGoogle ScholarPubMed
17.Marquette, CH, Copin, MC, Wallet, F et al. . Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard. Am J Respir Crit Care Med 1995; 151: 1878–1888.CrossRefGoogle ScholarPubMed
18.Sanchez-Nieto, JM, Torres, A, Garcia-Cordoba, F et al. . Impact of invasive and non-invasive quantitative culture sampling on outcome of ventilator-associated pneumonia. Am J Respir Crit Care Med 1998; 157: 371–376.CrossRefGoogle Scholar
19.Ruiz, M, Torres, A, Ewig, S et al. . Non-invasive vs. invasive microbial investigation in ventilator associated pneumonia: evaluation of outcome. Am J Respir Crit Care Med 2000; 162: 119–125.CrossRefGoogle Scholar
20.Camargo, LF, De Marco, FV, Barbas, CS et al. . Ventilator associated pneumonia: comparison between quantitative and qualitative cultures of tracheal aspirates. Crit Care 2004; 8: R422–R430.CrossRefGoogle ScholarPubMed
21.Wearden, PD, Chendrasekhar, A, Timberlake, GA. Comparison of nonbronchoscopic techniques with bronchoscopic brushing in the diagnosis of ventilator-associated pneumonia. J Trauma 1996; 41: 703–707.CrossRefGoogle ScholarPubMed
22.Shorr, AF, Sherner, JH, Jackson, WL et al. . Invasive approaches to the diagnosis of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 2005; 33: 46–53.CrossRefGoogle Scholar
23.Mehta, R, Niederman, MS. Adequate empirical therapy minimizes the impact of diagnostic methods in patients with ventilator-associated pneumonia. Crit Care Med 2000; 28: 3092–3094.CrossRefGoogle ScholarPubMed
24.Luna, CM, Vujacich, P, Niederman, MS et al. . Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest 1997; 111: 676–685.CrossRefGoogle ScholarPubMed
25.Kollef, MH, Sherman, G, Ward, S, Fraser, VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 1995; 115: 462–474.CrossRefGoogle Scholar
26.American Thoracic Society & 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.CrossRefGoogle Scholar
27.Torres, A, Aznar, R, Gatell, JM et al. . Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 1990; 142: 523–528.CrossRefGoogle ScholarPubMed
28.Paul, M, Benuri-Silbiger, I, Soares-Weiser, K, Leibovici, L. Beta lactam monotherapy vs. beta lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients: systematic review and meta-analysis of randomised trials. BMJ 2004; 328: 668–681.CrossRefGoogle Scholar
29.Rubinstein, E, Lode, H, Grassi, C. Ceftazidime monotherapy vs. ceftriaxone/tobramycin for serious hospital-acquired gram-negative infections. Antibiotic Study Group. Clin Infect Dis 1995; 20: 1217–1228.CrossRefGoogle ScholarPubMed
30.Damas, P, Garweg, C, Monchi, M et al. . Combination therapy vs. monotherapy: a randomised pilot study on the evolution of inflammatory parameters after ventilator associated pneumonia. Crit Care 2006; 10: R52.CrossRefGoogle Scholar
31.Ibrahim, EH, Ward, S, Sherman, G, Schaiff, R, Fraser, VJ, Kollef, MH. Experience with a clinical guideline for the treatment of ventilator-associated pneumonia. Crit Care Med 2001; 29: 1109–1115.CrossRefGoogle ScholarPubMed
32.Kollef, MH. Is there a role for antibiotic cycling in the intensive care unit? Crit Care Med 2001; 29 (4 Suppl): N135–N142.CrossRefGoogle Scholar
33.Kollef, MH, Vlasnik, J, Sharpless, L, Pasque, C, Murphy, D, Fraser, V. Scheduled change of antibiotic classes: a strategy to decrease the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 1997; 156: 1040–1048.CrossRefGoogle ScholarPubMed
34.Gruson, D, Hilbert, G, Vargas, F et al. . Rotation and restricted use of antibiotics in a medical intensive care unit. Impact on the incidence of ventilator-associated pneumonia caused by antibiotic-resistant gram-negative bacteria. Am J Respir Crit Care Med 2000; 162: 837–843.CrossRefGoogle Scholar
35.Chastre, J, Wolff, M, Fagon, JY et al. . Comparison of 8 vs. 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA 2003; 290: 2588–2598.CrossRefGoogle ScholarPubMed
36.Dodek, P, Keenan, S, Cook, D et al. . Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004; 141: 305–313.CrossRefGoogle ScholarPubMed
37.Heyland, DK, Cook, DJ, Dodek, PM. Prevention of ventilator-associated pneumonia: current practice in Canadian intensive care units. J Crit Care 2002; 17: 161–167.CrossRefGoogle ScholarPubMed
38.Drakulovic, MB, Torres, A, Bauer, TT, Nicolas, JM, Nogue, S, Ferrer, M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999; 354: 1851–1858.CrossRefGoogle ScholarPubMed
39.Kress, JP, Pohlman, AS, O’Connor, MF et al. . Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471–1477.CrossRefGoogle ScholarPubMed
40.S elective Decontamination of the Digestive Tract Trialists’ Collaborative Group. Meta-analysis of randomised controlled trials of selective decontamination of the digestive tract. BMJ 1993; 307: 525–532.CrossRefGoogle Scholar
41.Heyland, DK, Cook, DJ, Jaeschke, R, Griffith, L, Lee, HN, Guyatt, GH. Selective decontamination of the digestive tract. An overview. Chest 1994; 105: 1221–1229.CrossRefGoogle ScholarPubMed
42.Rumbak, MJ, Newton, M, Truncale, T et al. . A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004; 32: 1689–1694.CrossRefGoogle ScholarPubMed
43.2ndDeRiso, AJ, Ladowski, JS, Dillon, TA, Justice, JW, Peterson, AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use inpatients undergoing heart surgery. Chest 1996; 109: 1556–1561.CrossRefGoogle Scholar
44.Sirvent, JM, Torres, A, El-Ebiary, M, Castro, P, de Batlle, J, Bonet, A. Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma. Am J Respir Care Med 1997; 155: 1729–1734.CrossRefGoogle ScholarPubMed
45.Nourdine, K, Combes, P, Carton, MJ et al. . Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey. Intensive Care Med 1999; 25: 567–573.CrossRefGoogle Scholar
46.Valles, J, Artigas, A, Rello, J et al. . Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med 1995; 122: 179–186.CrossRefGoogle ScholarPubMed
47.Young, PJ, Basson, C, Hamilton, D, Ridley, SA. The pressure limited tracheal tube cuff: prevention of aspiration of oropharyngeal fluid to the lungs. Brit J Anaesth 1998; 81: 823P–824P.Google Scholar
48.Seegobin, RD, van Hasselt, GL. Aspiration beyond endotracheal cuffs. Can Anaesth Soc J 1986; 33: 273–279.CrossRefGoogle ScholarPubMed