Dear Editor,

The cumulative incidence of ventilator-associated pneumonia (VAP) among patients admitted to the intensive care unit (ICU) who have acquired an infection has been reported to be 10–25 %, accounting for 50 % of the antibiotics prescribed in the ICU [1] and increasing patient mortality by 20–55 % [2]. Implementing ventilator care bundles, as recommended in the National Healthcare Safety Network manual [3], reduces the risk of VAP and improves patient outcomes [2].

We conducted a retrospective study of patients admitted to the ICUs of a level-1 200-bed Indian trauma centre during a 3-year period (2011–2014) to evaluate the impact of intensive preventive efforts implemented to reduce the incidence of VAP. The data have been presented at an international conference [4].

In 2011, the trauma centre initiated a program consisting of frequent training sessions in which a microbiologist and an intensivist provided seminars and workshops to staff. A hospital infection control (HIC) manual was prepared and made available at points of patient care. Hand hygiene and ventilator bundle compliance were advocated, followed and regularly monitored by the HIC staff. Any inadequacies were communicated to the individual in charge of critical care.

During the study period 3474 patients were admitted to the ICUs of the trauma centre: 2433 to the neurosurgical ICU (NICU) and 1041 to the surgical ICU (SICU). Of these, 681 and 293 were mechanically ventilated in the NICU and SICU, respectively. All data were analyzed statistically using Stata version 11.2 (StataCorp, College Station, TX), and the analytical results are presented in the Electronic Supplementary Material. Ventilator bundle compliance and hand hygiene rate progressively increased over the 3-year study period, and in 2014 the overall increase in bundle compliance was 2 % (2011: 79.9 %; 2014: 82.4 %), with a 19 % increase in the NICU (2011: 67 %; 2014: 83.2 %). The percentage increase in hand hygiene rate in the NICU and SICU was 12 % (2011: 61.4 %; 2014: 64.6 %) and 5.5 % (2011: 56.4 %; 2014: 64.1 %), respectively.

The incidence of VAP was high in 2011 (13.4 and 17.6 per thousand ventilator days in the SICU and NICU, respectively), but by 2014 it had decreased (primary objective of the study) by 68  and 56 % in the NICU and SICU, respectively. The total number of VAP episodes remained the same (n = 22) in the SICU between 2011 and 2014 (p = 0.64, difference not significant), but a substantial reduction was achieved in the NICU (from 78 in 2011 to 28 in 2014; p = 0.001, statistically significant difference). The reduction in mortality rate during the study period was not significant in the SICU (p = 0.115), but was statistically significant in the NICU (p = 0.002). The trends of all outcomes are shown in Fig. 1.

Fig. 1
figure 1

Outcome parameters measures. a Ventilator-associated pneumonia (VAP) rate, b mortality rate among patients admitted to the intensive care units (ICU), c mean length of ICU stay, d duration of mechanical ventilation

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The substantial reduction in VAP rate in the ICUs was achieved by implementing a combination of preventive efforts within the framework of a quality improvement process. However, despite all efforts, VAP could not be eliminated, showing that there is still scope for improvement which could be attained by greater compliance to bundles and hand hygiene precluding sensitization of healthcare workers to implementation of HIC measures. Although implementation of the VAP prevention bundle is not the only parameter responsible for achieving a decrease in the VAP rate, it is the most essential step for controlling VAP occurrence.

To conclude, a dynamic cooperation between infection control and ICU staffs, the appointment of an infection control nurse to monitor bundle implementation, daily multidisciplinary rounds, periodic educational and training sessions, administrative support and the consistent adherence of healthcare workers to HIC protocols do enable a reduction in VAP rate [5].

To the best of our knowledge, this is first study of its kind from India as most Indian hospitals do not have infection control policies or systems to report healthcare-associated infections (HAI). The results of our study emphasize the need to generate HAI rates for all hospitals and to implement bundles to reduce HAI rates.