Drugs

, Volume 70, Issue 15, pp 1927–1944 | Cite as

Diagnosis, Management and Prevention of Ventilator-Associated Pneumonia

An Update
  • Jean-Louis Vincent
  • Dalton de Souza Barros
  • Silvia Cianferoni
Therapy In Practice

Abstract

Ventilator-associated pneumonia (VAP) affects 10–20% of mechanically ventilated patients and is associated with increased morbidity and mortality and high costs. Early diagnosis is crucial for rapid appropriate antimicrobial therapy to be instituted, but debate remains as to the optimal diagnostic strategy. Noninvasive clinical-based diagnosis is rapid but may not be as accurate as invasive techniques. Increased use of biomarkers and advances in genomics and proteomics may help speed up diagnosis. Management of VAP relies principally on appropriate antimicrobial therapy, which should be selected according to individual patient factors, such as previous antibacterial therapy and length of hospitalization or mechanical ventilation, and local infection and resistance patterns. In addition, once bacterial culture and sensitivity results are available, broad-spectrum therapy should be de-escalated to provide a more specific, narrower-spectrum cover. Optimum duration of antibacterial therapy is difficult to define and should be tailored to clinical response. Biomarker levels may be useful to monitor response to therapy. With the high morbidity and mortality, prevention of VAP is important and several strategies have been shown to reduce the rates of VAP in mechanically ventilated patients, including using noninvasive ventilation where possible, and semi-recumbent positioning. Other potentially beneficial preventive techniques include subglottal suctioning, oral decontamination strategies and antimicrobial-coated endotracheal tubes, although further study is needed to confirm the cost effectiveness of these strategies.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Hortal J, Munoz P, Cuerpo G, et al. Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe. Crit Care 2009; 13(3): R80PubMedGoogle Scholar
  2. 2.
    Muscedere JG, Martin CM, Heyland DK. The impact of ventilator-associated pneumonia on the Canadian health care system. J Crit Care 2008; 23(1): 5–10PubMedGoogle Scholar
  3. 3.
    Safdar N, Dezfulian C, Collard HR, et al. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 2005; 33(10): 2184–93PubMedGoogle Scholar
  4. 4.
    van der Kooi TI, Boer AS, Mannien J, et al. Incidence and risk factors of device-associated infections and associated mortality at the intensive care in the Dutch surveillance system. Intensive Care Med 2007; 33(2): 271–8PubMedGoogle Scholar
  5. 5.
    Koulenti D, Lisboa T, Brun-Buisson C, et al. Spectrum of practice in the diagnosis of nosocomial pneumonia in patients requiring mechanical ventilation in European intensive care units. Crit Care Med 2009; 37(8): 2360–8PubMedGoogle Scholar
  6. 6.
    Minei JP, Hawkins K, Moody B, et al. Alternative case definitions of ventilator-associated pneumonia identify different patients in a surgical intensive care unit. Shock 2000; 14(3): 331–6PubMedGoogle Scholar
  7. 7.
    Suetens C, Morales I, Savey A, et al. European surveillance of ICU-acquired infections (HELICS-ICU): methods and main results. J Hosp Infect 2007; 65 Suppl. 2: 171–3PubMedGoogle Scholar
  8. 8.
    Torres A, Ewig S, Lode H, et al. Defining, treating and preventing hospital acquired pneumonia: European perspective. Intensive Care Med 2009; 35(1): 9–29PubMedGoogle Scholar
  9. 9.
    Depuydt PO, Vandijck DM, Bekaert MA, et al. Determinants and impact of multidrug antibiotic resistance in pathogens causing ventilator-associated-pneumonia. Crit Care 2008; 12(6): R142PubMedGoogle Scholar
  10. 10.
    American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171(4): 388–416Google Scholar
  11. 11.
    Kollef MH, Shorr A, Tabak YP, et al. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 2005; 128(6): 3854–62PubMedGoogle Scholar
  12. 12.
    Hidron AI, Edwards JR, Patel J, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007. Infect Control Hosp Epidemiol 2008; 29(11): 996–1011PubMedGoogle Scholar
  13. 13.
    Boots RJ, Lipman J, Bellomo R, et al. The spectrum of practice in the diagnosis and management of pneumonia in patients requiring mechanical ventilation: Australian and New Zealand practice in intensive care (ANZPIC II). Anaesth Intensive Care 2005; 33(1): 87–100PubMedGoogle Scholar
  14. 14.
    Park DR. The microbiology of ventilator-associated pneumonia. Respir Care 2005; 50(6): 742–63PubMedGoogle Scholar
  15. 15.
    Rosenthal VD, Maki DG, Jamulitrat S, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003–2008, issued June 2009. Am J Infect Control 2010; 38(2): 95–104PubMedGoogle Scholar
  16. 16.
    Póvoa P, Coelho L, Almeida E, et al. C-reactive protein as a marker of infection in critically ill patients. Clin Microbiol Infect 2005; 11(2): 101–8PubMedGoogle Scholar
  17. 17.
    Póvoa P, Coelho L, Almeida E, et al. C-reactive protein as a marker of ventilator-associated pneumonia resolution: a pilot study. Eur Respir J 2005; 25(5): 804–12PubMedGoogle Scholar
  18. 18.
    Ramirez P, Garcia MA, Ferrer M, et al. Sequential measurements of procalcitonin levels in diagnosing ventilator-associated pneumonia. Eur Respir J 2008; 31(2): 356–62PubMedGoogle Scholar
  19. 19.
    Seligman R, Meisner M, Lisboa TC, et al. Decreases in procalcitonin and C-reactive protein are strong predictors of survival in ventilator-associated pneumonia. Crit Care 2006; 10(5): R125PubMedGoogle Scholar
  20. 20.
    Lisboa T, Seligman R, Diaz E, et al. C-reactive protein correlates with bacterial load and appropriate antibiotic therapy in suspected ventilator-associated pneumonia. Crit Care Med 2008; 36(1): 166–71PubMedGoogle Scholar
  21. 21.
    Luyt CE, Combes A, Reynaud C, et al. Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia. Intensive Care Med 2008; 34(8): 1434–40PubMedGoogle Scholar
  22. 22.
    Luyt CE, Guerin V, Combes A, et al. Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia. Am J Respir Crit Care Med 2005; 171(1): 48–53PubMedGoogle Scholar
  23. 23.
    Hillas G, Vassilakopoulos T, Plantza P, et al. C-reactive protein and procalcitonin as predictors of survival and septic shock in ventilator-associated pneumonia. Eur Respir J 2010; 35(4): 805–11PubMedGoogle Scholar
  24. 24.
    McDunn JE, Husain KD, Polpitiya AD, et al. Plasticity of the systemic inflammatory response to acute infection during critical illness: development of the riboleukogram. PLoS One 2008; 3(2): e1564PubMedGoogle Scholar
  25. 25.
    Cobb JP, Moore EE, Hayden DL, et al. Validation of the riboleukogram to detect ventilator-associated pneumonia after severe injury. Ann Surg. Epub 2009 Aug 27Google Scholar
  26. 26.
    Mentec H, May-Michelangeli L, Rabbat A, et al. Blind and bronchoscopic sampling methods in suspected ventilator-associated pneumonia: a multicentre prospective study. Intensive Care Med 2004; 30(7): 1319–26PubMedGoogle Scholar
  27. 27.
    Leo A, Galindo-Galindo J, Folch E, et al. Comparison of bronchoscopic bronchoalveolar lavage vs blind lavage with a modified nasogastric tube in the etiologic diagnosis of ventilator-associated pneumonia. Med Intensiva 2008; 32(3): 115–20PubMedGoogle Scholar
  28. 28.
    Conway Morris A, Kefala K, Wilkinson TS, et al. Diagnostic importance of pulmonary interleukin-1beta and interleukin-8 in ventilator-associated pneumonia. Thorax 2010; 65(3): 201–7PubMedGoogle Scholar
  29. 29.
    Determann RM, Millo JL, Gibot S, et al. Serial changes in soluble triggering receptor expressed on myeloid cells in the lung during development of ventilator-associated pneumonia. Intensive Care Med 2005; 31(11): 1495–500PubMedGoogle Scholar
  30. 30.
    Anand NJ, Zuick S, Klesney-Tait J, et al. Diagnostic implications of soluble triggering receptor expressed on myeloid cells-1 in BAL fluid of patients with pulmonary infiltrates in the ICU. Chest 2009; 135(3): 641–7PubMedGoogle Scholar
  31. 31.
    Oudhuis GJ, Beuving J, Bergmans D, et al. Soluble triggering receptor expressed on myeloid cells-1 in bronchoalveolar lavage fluid is not predictive for ventilator-associated pneumonia. Intensive Care Med 2009; 35(7): 1265–70PubMedGoogle Scholar
  32. 32.
    Fagon JY, Chastre J, Wolff M, et al. Invasive and non-invasive strategies for management of suspected ventilator-associated pneumonia: a randomized trial. Ann Intern Med 2000; 132(8): 621–30PubMedGoogle Scholar
  33. 33.
    Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006; 355(25): 2619–30Google Scholar
  34. 34.
    Marik PE, Baram M. Diagnosis of ventilator-associated pneumonia. N Engl J Med 2007; 356(14): 1470–1PubMedGoogle Scholar
  35. 35.
    Fujitani S, Cohen-Melamed MH, Tuttle RP, et al. Comparison of semi-quantitative endotracheal aspirates to quantitative non-bronchoscopic bronchoalveolar lavage in diagnosing ventilator-associated pneumonia. Respir Care 2009; 54(11): 1453–61PubMedGoogle Scholar
  36. 36.
    Mondi MM, Chang MC, Bowton DL, et al. Prospective comparison of bronchoalveolar lavage and quantitative deep tracheal aspirate in the diagnosis of ventilator associated pneumonia. J Trauma 2005; 59(4): 891–5PubMedGoogle Scholar
  37. 37.
    Brun-Buisson C, Fartoukh M, Lechapt E, et al. Contribution of blinded, protected quantitative specimens to the diagnostic and therapeutic management of ventilator-associated pneumonia. Chest 2005; 128(2): 533–44PubMedGoogle Scholar
  38. 38.
    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(1): 46–53PubMedGoogle Scholar
  39. 39.
    Berton DC, Kalil AC, Cavalcanti M, et al. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database Syst Rev 2008; (4): CD006482Google Scholar
  40. 40.
    Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and treatment. J Crit Care 2008; 23(1): 138–47PubMedGoogle Scholar
  41. 41.
    Luna CM, Aruj P, Niederman MS, et al. Appropriateness and delay to initiate therapy in ventilator-associated pneumonia. Eur Respir J 2006; 27(1): 158–64PubMedGoogle Scholar
  42. 42.
    Teixeira PJ, Seligman R, Hertz FT, et al. Inadequate treatment of ventilator-associated pneumonia: risk factors and impact on outcomes. J Hosp Infect 2007; 65(4): 361–7PubMedGoogle Scholar
  43. 43.
    Kuti EL, Patel AA, Coleman CI. Impact of inappropriate antibiotic therapy on mortality in patients with ventilator-associated pneumonia and blood stream infection: a meta-analysis. J Crit Care 2008; 23(1): 91–100PubMedGoogle Scholar
  44. 44.
    Micek ST, Ward S, Fraser VJ, et al. A randomized controlled trial of an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia. Chest 2004; 125(5): 1791–9PubMedGoogle Scholar
  45. 45.
    Eachempati SR, Hydo LJ, Shou J, et al. Does de-escalation of antibiotic therapy for ventilator-associated pneumonia affect the likelihood of recurrent pneumonia or mortality in critically ill surgical patients? J Trauma 2009; 66(5): 1343–8PubMedGoogle Scholar
  46. 46.
    Kollef MH, Morrow LE, Niederman MS, et al. Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest 2006; 129(5): 1210–8PubMedGoogle Scholar
  47. 47.
    Wunderink RG, Rello J, Cammarata SK, et al. Linezolid vs vancomycin: analysis of two double-blind studies of patients with methicillin-resistant Staphylococcus aureus nosocomial pneumonia. Chest 2003; 124(5): 1789–97PubMedGoogle Scholar
  48. 48.
    Wunderink RG, Mendelson MH, Somero MS, et al. Early microbiological response to linezolid vs vancomycin in ventilator-associated pneumonia due to methicillin-resistant Staphylococcus aureus. Chest 2008; 134(6): 1200–7PubMedGoogle Scholar
  49. 49.
    Boselli E, Breilh D, Rimmele T, et al. Alveolar concentrations of piperacillin/tazobactam administered in continuous infusion to patients with ventilator-associated pneumonia. Crit Care Med 2008; 36(5): 1500–6PubMedGoogle Scholar
  50. 50.
    Damas P, Garweg C, Monchi M, et al. Combination therapy versus monotherapy: a randomised pilot study on the evolution of inflammatory parameters after ventilator associated pneumonia [ISRCTN31976779]. Crit Care 2006; 10(2): R52PubMedGoogle Scholar
  51. 51.
    Garnacho-Montero J, Sa-Borges M, Sole-Violan J, et al. Optimal management therapy for Pseudomonas aeruginosa ventilator-associated pneumonia: an observational, multicenter study comparing monotherapy with combination antibiotic therapy. Crit Care Med 2007; 35(8): 1888–95PubMedGoogle Scholar
  52. 52.
    Heyland DK, Dodek P, Muscedere J, et al. Randomized trial of combination versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia. Crit Care Med 2008; 36(3): 737–44PubMedGoogle Scholar
  53. 53.
    Papazian L. How can earlier antibiotic efficacy be provided for ventilator-associated pneumonia without promoting bacterial resistance? Is initial monotherapy or a combination of antibiotics the right answer? Crit Care Med 2008; 36(3): 994–5PubMedGoogle Scholar
  54. 54.
    Aarts MA, Hancock JN, Heyland D, et al. Empiric antibiotic therapy for suspected ventilator-associated pneumonia: a systematic review and meta-analysis of randomized trials. Crit Care Med 2008; 36(1): 108–17PubMedGoogle Scholar
  55. 55.
    Combes A, Luyt CE, Fagon JY, et al. Early predictors for infection recurrence and death in patients with ventilator-associated pneumonia. Crit Care Med 2007; 35(1): 146–54PubMedGoogle Scholar
  56. 56.
    Stolz D, Smyrnios N, Eggimann P, et al. Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study. Eur Respir J 2009; 34(6): 1364–75PubMedGoogle Scholar
  57. 57.
    Mueller EW, Croce MA, Boucher BA, et al. Repeat bronchoalveolar lavage to guide antibiotic duration for ventilator-associated pneumonia. J Trauma 2007; 63(6): 1329–37PubMedGoogle Scholar
  58. 58.
    Bouza E, Torres MV, Radice C, et al. Direct E-test (AB Biodisk) of respiratory samples improves antimicrobial use in ventilator-associated pneumonia. Clin Infect Dis 2007; 44(3): 382–7PubMedGoogle Scholar
  59. 59.
    Shorr AF, Cook D, Jiang X, et al. Correlates of clinical failure in ventilator-associated pneumonia: insights from a large, randomized trial. J Crit Care 2008; 23(1): 64–73PubMedGoogle Scholar
  60. 60.
    Hallal A, Cohn SM, Namias N, et al. Aerosolized tobramycin in the treatment of ventilator-associated pneumonia: a pilot study. Surg Infect (Larchmt) 2007; 8(1): 73–82Google Scholar
  61. 61.
    Michalopoulos A, Kasiakou SK, Mastora Z, et al. Aerosolized colistin for the treatment of nosocomial pneumonia due to multidrug-resistant Gram-negative bacteria in patients without cystic fibrosis. Crit Care 2005; 9(1): R53–9PubMedGoogle Scholar
  62. 62.
    Michalopoulos A, Fotakis D, Virtzili S, et al. Aerosolized colistin as adjunctive treatment of ventilator-associated pneumonia due to multidrug-resistant Gram-negative bacteria: a prospective study. Respir Med 2008; 102(3): 407–12PubMedGoogle Scholar
  63. 63.
    Ioannidou E, Siempos II, Falagas ME. Administration of antimicrobials via the respiratory tract for the treatment of patients with nosocomial pneumonia: a meta-analysis. J Antimicrob Chemother 2007; 60(6): 1216–26PubMedGoogle Scholar
  64. 64.
    Giamarellos-Bourboulis EJ, Pechere JC, Routsi C, et al. Effect of clarithromycin in patients with sepsis and ventilator-associated pneumonia. Clin Infect Dis 2008; 46(8): 1157–64PubMedGoogle Scholar
  65. 65.
    Siempos II, Vardakas KZ, Kopterides P, et al. Adjunctive therapies for community-acquired pneumonia: a systematic review. J Antimicrob Chemother 2008; 62(4): 661–8PubMedGoogle Scholar
  66. 66.
    Majumdar SR, McAlister FA, Eurich DT, et al. Statins and outcomes in patients admitted to hospital with community acquired pneumonia: population based prospective cohort study. BMJ 2006; 333(7576): 999PubMedGoogle Scholar
  67. 67.
    Thomsen RW, Riis A, Kornum JB, et al. Preadmission use of statins and outcomes after hospitalization with pneumonia: population-based cohort study of 29,900 patients. Arch Intern Med 2008; 168(19): 2081–7PubMedGoogle Scholar
  68. 68.
    Chalmers JD, Singanayagam A, Murray MP, et al. Prior statin use is associated with improved outcomes in community-acquired pneumonia. Am J Med 2008; 121(11): 1002–7PubMedGoogle Scholar
  69. 69.
    Kopterides P, Falagas ME. Statins for sepsis: a critical and updated review. Clin Microbiol Infect 2009; 15(4): 325–34PubMedGoogle Scholar
  70. 70.
    Pravastatin and ventilatory associated pneumonia (EPRA-VAP) [ClinicalTrials.gov identifier NCT00702130]. US National Institutes of Health, ClinicalTrials.gov [online]. Available from URL: http://www.clinicaltrials.gov [Accessed 2010 Jul 29]
  71. 71.
    Vincent JL. Nosocomial infections in adult intensive-care units. Lancet 2003; 361(9374): 2068–77PubMedGoogle Scholar
  72. 72.
    Falagas ME, Siempos II, Bliziotis IA, et al. Administration of antibiotics via the respiratory tract for the prevention of ICU-acquired pneumonia: a meta-analysis of comparative trials. Crit Care 2006; 10(4): R123PubMedGoogle Scholar
  73. 73.
    Manzano F, Fernandez-Mondejar E, Colmenero M, et al. Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients. Crit Care Med 2008; 36(8): 2225–31PubMedGoogle Scholar
  74. 74.
    Morrow LE, Kollef MH, Casale TB. Probiotic prophylaxis of ventilator-associated pneumonia: a blinded, randomized, controlled trial. Am J Respir Crit Care Med. Epub 2010 Jun 3Google Scholar
  75. 75.
    Siempos II, Ntaidou TK, Falagas ME. Impact of the administration of probiotics on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. Crit Care Med 2010; 38(3): 954–62PubMedGoogle Scholar
  76. 76.
    Barraud D, Blard C, Hein F, et al. Probiotics in the critically ill patient: a double blind, randomized, placebo-controlled trial. Intensive Care Med. Epub 2010 May 26Google Scholar
  77. 77.
    Quenot JP, Ladoire S, Devoucoux F, et al. Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia. Crit Care Med 2007; 35(9): 2031–6PubMedGoogle Scholar
  78. 78.
    Nseir S, Favory R, Jozefowicz E, et al. Antimicrobial treatment for ventilator-associated tracheobronchitis: a randomized, controlled, multicenter study. Crit Care 2008; 12(3): R62PubMedGoogle Scholar
  79. 79.
    Palmer LB, Smaldone GC, Chen JJ, et al. Aerosolized antibiotics and ventilator-associated tracheobronchitis in the intensive care unit. Crit Care Med 2008; 36(7): 2008–13PubMedGoogle Scholar
  80. 80.
    Dallas J, Kollef M. VAT vs VAP: are we heading toward clarity or confusion? Chest 2009; 135(2): 252–5PubMedGoogle Scholar
  81. 81.
    Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA 2010; 303(15): 1483–9PubMedGoogle Scholar
  82. 82.
    Staudinger T, Bojic A, Holzinger U, et al. Continuous lateral rotation therapy to prevent ventilator-associated pneumonia. Crit Care Med 2010; 38(2): 486–90PubMedGoogle Scholar
  83. 83.
    Alsaghir AH, Martin CM. Effect of prone positioning in patients with acute respiratory distress syndrome: a meta-analysis. Crit Care Med 2008; 36(2): 603–9PubMedGoogle Scholar
  84. 84.
    Kopterides P, Siempos II, Armaganidis A. Prone positioning in hypoxemic respiratory failure: meta-analysis of randomized controlled trials. J Crit Care 2009; 24(1): 89–100PubMedGoogle Scholar
  85. 85.
    Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999; 354(9193): 1851–8PubMedGoogle Scholar
  86. 86.
    Alexiou VG, Ierodiakonou V, Dimopoulos G, et al. Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. J Crit Care 2009; 24(4): 515–22PubMedGoogle Scholar
  87. 87.
    Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med 2005; 33(6): 1225–9PubMedGoogle Scholar
  88. 88.
    Van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006; 34(2): 396–402PubMedGoogle Scholar
  89. 89.
    Chao YF, Chen YY, Wang KW, et al. Removal of oral secretion prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: a clinical controlled trial study. J Clin Nurs 2009; 18(1): 22–8PubMedGoogle Scholar
  90. 90.
    Lacherade JC, Auburtin M, Cerf C, et al. Impact of humidification systems on ventilator-associated pneumonia: a randomized multicenter trial. Am J Respir Crit Care Med 2005; 172(10): 1276–82PubMedGoogle Scholar
  91. 91.
    Boots RJ, George N, Faoagali JL, et al. Double-heaterwire circuits and heat-and-moisture exchangers and the risk of ventilator-associated pneumonia. Crit Care Med 2006; 34(3): 687–93PubMedGoogle Scholar
  92. 92.
    Lorente L, Lecuona M, Jimenez A, et al. Ventilator-associated pneumonia using a heated humidifier or a heat and moisture exchanger: a randomized controlled trial [ISRCTN88724583]. Crit Care 2006; 10(4): R116PubMedGoogle Scholar
  93. 93.
    Siempos II, Vardakas KZ, Kopterides P, et al. Impact of passive humidification on clinical outcomes of mechanically ventilated patients: a meta-analysis of randomized controlled trials. Crit Care Med 2007; 35(12): 2843–51PubMedGoogle Scholar
  94. 94.
    Lorente L, Lecuona M, Martin MM, et al. Ventilator-associated pneumonia using a closed versus an open tracheal suction system. Crit Care Med 2005; 33(1): 115–9PubMedGoogle Scholar
  95. 95.
    Lorente L, Lecuona M, Jimenez A, et al. Tracheal suction by closed system without daily change versus open system. Intensive Care Med 2006; 32(4): 538–44PubMedGoogle Scholar
  96. 96.
    Vonberg RP, Eckmanns T, Welte T, et al. Impact of the suctioning system (open vs. closed) on the incidence of ventilation-associated pneumonia: meta-analysis of randomized controlled trials. Intensive Care Med 2006; 32(9): 1329–35Google Scholar
  97. 97.
    Subirana M, Sola I, Benito S. Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients. Cochrane Database Syst Rev2007;(4):CD004581Google Scholar
  98. 98.
    Jongerden IP, Rovers MM, Grypdonck MH, et al. Open and closed endotracheal suction systems in mechanically ventilated intensive care patients: a meta-analysis. Crit Care Med 2007; 35(1): 260–70PubMedGoogle Scholar
  99. 99.
    Siempos II, Vardakas KZ, Falagas ME. Closed tracheal suction systems for prevention of ventilator-associated pneumonia. Br J Anaesth 2008; 100(3): 299–306PubMedGoogle Scholar
  100. 100.
    Niel-Weise BS, Snoeren RL, van den Broek PJ. Policies for endotracheal suctioning of patients receiving mechanical ventilation: a systematic review of randomized controlled trials. Infect Control Hosp Epidemiol 2007; 28(5): 531–6PubMedGoogle Scholar
  101. 101.
    Caruso P, Denari S, Ruiz SA, et al. Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit Care Med 2009; 37(1): 32–8PubMedGoogle Scholar
  102. 102.
    Dezfulian C, Shojania K, Collard HR, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med 2005; 118(1): 11–8PubMedGoogle Scholar
  103. 103.
    Lorente L, Lecuona M, Jimenez A, et al. Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am J Respir Crit Care Med 2007; 176(11): 1079–83PubMedGoogle Scholar
  104. 104.
    Kollef MH, Afessa B, Anzueto A, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA 2008; 300(7): 805–13PubMedGoogle Scholar
  105. 105.
    Chastre J. Preventing ventilator-associated pneumonia: could silver-coated endotracheal tubes be the answer? JAMA 2008; 300(7): 842–4PubMedGoogle Scholar
  106. 106.
    Kollef M, Pittet D, Sanchez GM, et al. A randomized double-blind trial of iseganan in prevention of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006; 173(1): 91–7PubMedGoogle Scholar
  107. 107.
    Fourrier F, Dubois D, Pronnier P, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med 2005; 33(8): 1728–35PubMedGoogle Scholar
  108. 108.
    Seguin P, Tanguy M, Laviolle B, et al. Effect of oropharyngeal decontamination by povidone-iodine on ventilator-associated pneumonia in patients with head trauma. Crit Care Med 2006; 34(5): 1514–9PubMedGoogle Scholar
  109. 109.
    Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006; 173(12): 1348–55PubMedGoogle Scholar
  110. 110.
    Tantipong H, Morkchareonpong C, Jaiyindee S, et al. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol 2008; 29(2): 131–6PubMedGoogle Scholar
  111. 111.
    Chan EY, Ruest A, Meade MO, et al. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007; 334(7599): 889PubMedGoogle Scholar
  112. 112.
    Panchabhai TS, Dangayach NS, Krishnan A, et al. Oro-pharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest 2009; 135(5): 1150–6PubMedGoogle Scholar
  113. 113.
    Bellissimo-Rodrigues F, Bellissimo-Rodrigues WT, Viana JM, et al. Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infect Control Hosp Epidemiol 2009; 30(10): 952–8PubMedGoogle Scholar
  114. 114.
    Scannapieco FA, Yu J, Raghavendran K, et al. A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Crit Care 2009; 13(4):R117PubMedGoogle Scholar
  115. 115.
    Miller RS, Norris PR, Jenkins JM, et al. Systems initiatives reduce healthcare-associated infections: a study of 22,928 device days in a single trauma unit. J Trauma 2010; 68(1): 23–31PubMedGoogle Scholar
  116. 116.
    Papadimos TJ, Hensley SJ, Duggan JM, et al. Implementation of the “FASTHUG” concept decreases the incidence of ventilator-associated pneumonia in a surgical intensive care unit. Patient Saf Surg 2008; 2: 3PubMedGoogle Scholar
  117. 117.
    Zaydfudim V, Dossett LA, Starmer JM, et al. Implementation of a real-time compliance dashboard to help reduce SICU ventilator-associated pneumonia with the ventilator bundle. Arch Surg 2009; 144(7): 656–62PubMedGoogle Scholar
  118. 118.
    Weireter Jr LJ, Collins JN, Britt RC, et al. Impact of a monitored program of care on incidence of ventilatorassociated pneumonia: results of a longterm performanceimprovement project. J Am Coll Surg 2009; 208(5): 700–4PubMedGoogle Scholar
  119. 119.
    Marra AR, Cal RG, Silva CV, et al. Successful prevention of ventilator-associated pneumonia in an intensive care setting. Am J Infect Control 2009; 37(8): 619–25PubMedGoogle Scholar
  120. 120.
    Bonello RS, Fletcher CE, Becker WK, et al. An intensive care unit quality improvement collaborative in nine Department of Veterans Affairs hospitals: reducing ventilator-associated pneumonia and catheter-related bloodstream infection rates. Jt Comm J Qual Patient Saf 2008; 34(11): 639–45PubMedGoogle Scholar
  121. 121.
    Bloos F, Muller S, Harz A, et al. Effects of staff training on the care of mechanically ventilated patients: a prospective cohort study. Br J Anaesth 2009; 103(2): 232–7PubMedGoogle Scholar
  122. 122.
    Omrane R, Eid J, Perreault MM, et al. Impact of a protocol for prevention of ventilator-associated pneumonia. Ann Pharmacother 2007; 41(9): 1390–6PubMedGoogle Scholar
  123. 123.
    Klompas M. The paradox of ventilator-associated pneumonia prevention measures. Crit Care 2009; 13(5): 315PubMedGoogle Scholar
  124. 124.
    Klompas M, Platt R. Ventilator-associated pneumonia: the wrong quality measure for benchmarking. Ann Intern Med 2007; 147(11): 803–5PubMedGoogle Scholar

Copyright information

© Adis Data Information BV 2010

Authors and Affiliations

  • Jean-Louis Vincent
    • 1
  • Dalton de Souza Barros
    • 1
  • Silvia Cianferoni
    • 1
  1. 1.Department of Intensive Care, Erasme University HospitalUniversité Libre de BruxellesBrusselsBelgium

Personalised recommendations