Prevention of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia

  • Stefano Bambi


Hospital-acquired pneumonia (HAP) is the most frequent hospital infection after urinary tract infection, while it is at the first place in ICU. Actually, a HAP in ventilated patients is a ventilator-associated pneumonia. HAP and VAP determine increases in hospital lengths of stay and costs than patients without HAP or VAP. HAP and VAP are classified as early onset (≤4 days) and late onset (>4 days). The mortality rates of early- and late-onset HAP or VAP are comparable. VAP is the main issue in ICU. Currently there is no gold standard for VAP diagnosis. The Centers for Disease Control and Prevention recently drafted some new surveillance definitions, introducing a tiered classification of ventilator-associated events for adult patients. Currently, the VAP preventive interventions are focused on three areas: reducing the time at risk, preventing endotracheal tube colonization, and minimizing contaminated modulation of colonization. Nurses play a fundamental role in the management of lots of these interventions. VAP bundle of care can be a useful tool set for prevention. However, there is a potential conflict coming from the absence of evidence of effectiveness about some bundle intervention and the need to implement it emerging from the common sense, as the case of 30° HOB elevation. Effective prevention strategies for VAP and HAI include professional, organizational, financial, and regulatory interventions.


Primary prevention Ventilator-associated pneumonia Nursing Critical care outcomes Cross infection 


  1. 1.
    Flodgren G, Conterno LO, Mayhew A, Omar O, Pereira CR, Shepperd S. Interventions to improve professional adherence to guidelines for prevention of device-related infections. Cochrane Database Syst Rev. 2013;3:CD006559. Scholar
  2. 2.
    Majumdar SS, Padiglione AA. Nosocomial infections in the intensive care unit. Anaesthesia & Intensive Care Medicine. 2012;13:204–8. Scholar
  3. 3.
    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. Scholar
  4. 4.
    Franzetti F, Antonelli M, Bassetti M, Blasi F, Langer M, Scaglione F, et al. Consensus document on controversial issues for the treatment of hospital-associated pneumonia. Int J Infect Dis. 2010;14:S55–65. Scholar
  5. 5.
    Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol. 2008;19:19–53.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Joseph NM, Sistla S, Dutta TK, Badhe AS, Parija SC. Ventilator-associated pneumonia: a review. Eur J Intern Med. 2010;21:360–8. Scholar
  7. 7.
    Torres A, Ferrer M, Badia JR. Treatment guidelines and outcomes of hospital-acquired and ventilator-associated pneumonia. Clin Infect Dis. 2010;51:S48–53. Scholar
  8. 8.
    Kollef MH, Morrow LE, Baughman RP, Craven DE, McGowan JE Jr, Micek ST, et al. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes-proceedings of the HCAP summit. Clin Infect Dis. 2008;46:S296–334. Scholar
  9. 9.
    Ewig S, Welte T, Torres A. Is healthcare-associated pneumonia a distinct entity needing specific therapy? Curr Opin Infect Dis. 2012;25:166–75. Scholar
  10. 10.
    Komiya K, Ishii H, Kadota J. Healthcare-associated pneumonia and aspiration pneumonia. Aging Dis. 2015;6:27–37. 10.14336/AD.2014.0127.CrossRefPubMedGoogle Scholar
  11. 11.
    Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis. 2014;58:330–9. Scholar
  12. 12.
    Albertos R, Caralt B, Rello J. Ventilator-associated pneumonia management in critical illness. Curr Opin Gastroenterol. 2011;27:160–6. Scholar
  13. 13.
    Kalanuria AA, Zai W, Mirski M. Ventilator-associated pneumonia in the ICU. Crit Care. 2014;18:208. Scholar
  14. 14.
    Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35:915–36. Scholar
  15. 15.
    Charles MP, Kali A, Easow JM, Joseph NM, Ravishankar M, Srinivasan S, et al. Ventilator-associated pneumonia. Australas Med J. 2014;7:334–44. Scholar
  16. 16.
    Efrati S, Deutsch I, Antonelli M, Hockey PM, Rozenblum R, Gurman GM. Ventilator-associated pneumonia: current status and future recommendations. J Clin Monit Comput. 2010;24:161–8. Scholar
  17. 17.
    Center for Disease Control and Prevention. Ventilator-Associated Event (VAE). For use in adult locations only. January 2016. Accessed 02 Jan 2016.
  18. 18.
    Guillamet CV, Kollef MH. Ventilator associated pneumonia in the ICU: where has it gone? Curr Opin Pulm Med. 2015;21:226–31. Scholar
  19. 19.
    Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–6. Scholar
  20. 20.
    Canadian Task Force on Preventive Health Care. Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). Accessed 19 Dec 2015.
  21. 21.
    Bouadma L, Wolff M, Lucet JC. Ventilator-associated pneumonia and its prevention. Curr Opin Infect Dis. 2012;25:395–404. Scholar
  22. 22.
    Cabrini L, Landoni G, Oriani A, Plumari VP, Nobile L, Greco M, et al. Noninvasive ventilation and survival in acute care settings: a comprehensive systematic review and metaanalysis of randomized controlled trials. Crit Care Med. 2015;43:880–8. Scholar
  23. 23.
    Balas MC, Vasilevskis EE, Burke WJ, Boehm L, Pun BT, Olsen KM, et al. Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Crit Care Nurse. 2012;32:35–38, 40-7. Scholar
  24. 24.
    Depew CL, McCarthy MS. Subglottic secretion drainage: a literature review. AACN Adv Crit Care. 2007;18:366–79. Scholar
  25. 25.
    Wang F, Bo L, Tang L, Lou J, Wu Y, Chen F, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: an updated meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2012;72:1276–85. Scholar
  26. 26.
    Han J, Liu Y. Effect of ventilator circuit changes on ventilator-associated pneumonia: a systematic review and meta-analysis. Respir Care. 2010;55:467–74.PubMedGoogle Scholar
  27. 27.
    Niël-Weise BS, Gastmeier P, Kola A, Vonberg RP, Wille JC, van den Broek PJ, et al. An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Crit Care. 2011;15:R111. Scholar
  28. 28.
    Metheny NA, Frantz RA. Head-of-bed elevation in critically ill patients: a review. Crit Care Nurse. 2013;33:53–66. Scholar
  29. 29.
    Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis. 2011;11:845–54. Scholar
  30. 30.
    Dullenkopf A, Gerber A, Weiss M. Fluid leakage past tracheal tube cuffs: evaluation of the new microcuff endotracheal tube. Intensive Care Med. 2003;29:1849–53. Scholar
  31. 31.
    Rose L, Redl L. Survey of cuff management practices in intensive care units in Australia and New Zealand. Am J Crit Care. 2008;17:428–35.PubMedGoogle Scholar
  32. 32.
    American Association for Respiratory Care. AARC clinical practice guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55:758–64.Google Scholar
  33. 33.
    Gu WJ, Gong YZ, Pan L, Ni YX, Liu JC. Impact of oral care with versus without toothbrushing on the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2012;16:R190. Scholar
  34. 34.
    Hickman J, Millett DT, Sander L, Brown E, Love J. Powered vs manual tooth brushing in fixed appliance patients: a short term randomized clinical trial. Angle Orthod. 2002;72:135–40.<0135:PVMTBI>2.0.CO;2.CrossRefPubMedGoogle Scholar
  35. 35.
    Tokmaji G, Vermeulen H, Müller MC, Kwakman PH, Schultz MJ, Zaat SA. Silver-coated endotracheal tubes for prevention of ventilator-associated pneumonia in critically ill patients. Cochrane Database Syst Rev. 2015;12(8):CD009201. Scholar
  36. 36.
    Hess DR. Patient positioning and ventilator-associated pneumonia. Respir Care. 2005;50:892–8; discussion 898-9PubMedGoogle Scholar
  37. 37.
    Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004;141:305–13.CrossRefPubMedGoogle Scholar
  38. 38.
    Andriolo BN, Andriolo RB, Saconato H, Atallah ÁN, Valente O. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. 2015;1:CD007271. Scholar
  39. 39.
    Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, et al. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009;33:122–67. Scholar
  40. 40.
    Reignier J, Mercier E, Le Gouge A, Boulain T, Desachy A, Bellec F, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309:249–56. Scholar
  41. 41.
    Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506–17. Scholar
  42. 42.
    Subirana M, Solà I, Benito S. Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients. Cochrane Database Syst Rev. 2007;4:CD004581. Scholar
  43. 43.
    Kollef MH, Prentice D, Shapiro SD, Fraser VJ, Silver P, Trovillion E, et al. Mechanical ventilation with or without daily changes of in-line suction catheters. Am J Respir Crit Care Med. 1997;156:466–72. Scholar
  44. 44.
    Ntoumenopoulos G, Presneill JJ, McElholum M, Cade JF. Chest physiotherapy for the prevention of ventilator-associated pneumonia. Intensive Care Med. 2002;28:850–6. Scholar
  45. 45.
    Tsai HH, Lin FC, Chang SC. Intermittent suction of oral secretions before each positional change may reduce ventilator-associated pneumonia: a pilot study. Am J Med Sci. 2008;336:397–401. Scholar
  46. 46.
    Chow MC, Kwok SM, Luk HW, Law JW, Leung BP. Effect of continuous oral suctioning on the development of ventilator-associated pneumonia: a pilot randomized controlled trial. Int J Nurs Stud. 2012;49:1333–41. Scholar
  47. 47.
    Kelly M, Gillies D, Todd DA, Lockwood C. Heated humidification versus heat and moisture exchangers for ventilated adults and children. Cochrane Database Syst Rev. 2010;4:CD004711. Scholar
  48. 48.
    Restrepo RD, Walsh BK, American Association for Respiratory Care. Humidification during invasive and noninvasive mechanical ventilation: 2012. Respir Care. 2012;57:782–8. Scholar
  49. 49.
    Chahoud J, Semaan A, Almoosa KF. Ventilator-associated events prevention, learning lessons from the past: a systematic review. Heart Lung. 2015;44:251–9. Scholar
  50. 50.
    Wip C, Napolitano L. Bundles to prevent ventilator-associated pneumonia: how valuable are they? Curr Opin Infect Dis. 2009;22:159–66. Scholar
  51. 51.
    Camporota L, Brett S. Care bundles: implementing evidence or common sense? Crit Care. 2011;15:159. Scholar
  52. 52.
    Scottish Intensive Care Society Audit Group. VAP Prevention Bundle. Guidance for implementation. NHS National Services Scotland. 2012. Accessed 18 Dec 2015.
  53. 53.
    Hampton DC, Griffith D, Howard A. Evidence-based clinical improvement for mechanically ventilated patients. Rehabil Nurs. 2005;30:160–5.CrossRefPubMedGoogle Scholar
  54. 54.
    Møller AH, Hansen L, Jensen MS, Ehlers LH. A cost effectiveness analysis of reducing ventilator associated pneumonia at a Danish ICU with ventilator bundle. J Med Econ. 2012;15:285–92. Scholar
  55. 55.
    Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8:1–72.CrossRefGoogle Scholar
  56. 56.
    Ranji SR, Shetty K, Posley KA, Lewis R, Sundaram V, Galvin C, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 6: Prevention of Healthcare–Associated Infections). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jan. (Technical Reviews, No. 9.6.) Accessed 14 Dec 2015.
  57. 57.
    Mauger B, Marbella A, Pines E, Chopra R, Black ER, Aronson N. Implementing quality improvement strategies to reduce healthcare-associated infections: a systematic review. Am J Infect Control. 2014;42:S274–83. Scholar
  58. 58.
    Rello J, Afonso E, Lisboa T, Ricart M, Balsera B, Rovira A, et al. A care bundle approach for prevention of ventilator-associated pneumonia. Clin Microbiol Infect. 2013;19:363–9. Scholar
  59. 59.
    Hamishehkar H, Vahidinezhad M, Mashayekhi SO, Asgharian P, Hassankhani H, Mahmoodpoor A. Education alone is not enough in ventilator associated pneumonia care bundle compliance. J Res Pharm Pract. 2014;3:51–5. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Stefano Bambi
    • 1
  1. 1.Emergency & Trauma ICU, University Hospital CareggiFlorenceItaly

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