Risk factors and prevention of hospital-acquired and ventilator-associated pneumonia in adults
- Thomas M File, Jr, MD
Thomas M File, Jr, MD
- Professor of Medicine
- Northeast Ohio Medical University
Hospital-acquired (or nosocomial) pneumonia (HAP) and ventilator-associated pneumonia (VAP) are important causes of morbidity and mortality despite improved antimicrobial therapy, supportive care, and prevention. The risk factors and prevention of HAP and VAP will be reviewed here.
The clinical presentation, diagnosis, epidemiology, pathogenesis, microbiology, and treatment of HAP and VAP are discussed separately. (See "Clinical presentation and diagnosis of ventilator-associated pneumonia" and "Epidemiology, pathogenesis, microbiology, and diagnosis of hospital-acquired and ventilator-associated pneumonia in adults" and "Treatment of hospital-acquired and ventilator-associated pneumonia in adults".)
Pneumonia types — The 2016 Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) guidelines distinguish the following types of pneumonia :
●Hospital-acquired (or nosocomial) pneumonia (HAP) is pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admission.
●Ventilator-associated pneumonia (VAP) is a type of pneumonia that develops more than 48 to 72 hours after endotracheal intubation.
- Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61.
- 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.
- Paterson DL. The epidemiological profile of infections with multidrug-resistant Pseudomonas aeruginosa and Acinetobacter species. Clin Infect Dis 2006; 43 Suppl 2:S43.
- Craven DE, Kunches LM, Kilinsky V, et al. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 1986; 133:792.
- Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med 2004; 32:1396.
- Bornstain C, Azoulay E, De Lassence A, et al. Sedation, sucralfate, and antibiotic use are potential means for protection against early-onset ventilator-associated pneumonia. Clin Infect Dis 2004; 38:1401.
- Celis R, Torres A, Gatell JM, et al. Nosocomial pneumonia. A multivariate analysis of risk and prognosis. Chest 1988; 93:318.
- Kollef MH, Von Harz B, Prentice D, et al. Patient transport from intensive care increases the risk of developing ventilator-associated pneumonia. Chest 1997; 112:765.
- Torres A, Gatell JM, Aznar E, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 1995; 152:137.
- Kollef MH. Ventilator-associated pneumonia. A multivariate analysis. JAMA 1993; 270:1965.
- Kollef MH, Vlasnik J, Sharpless L, et al. Scheduled change of antibiotic classes: a strategy to decrease the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 1997; 156:1040.
- Chastre J, Trouillet JL, Vuagnat A, et al. Nosocomial pneumonia in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 1998; 157:1165.
- Coffin SE, Klompas M, Classen D, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29 Suppl 1:S31.
- Hortal J, Giannella M, Pérez MJ, et al. Incidence and risk factors for ventilator-associated pneumonia after major heart surgery. Intensive Care Med 2009; 35:1518.
- Sopena N, Heras E, Casas I, et al. Risk factors for hospital-acquired pneumonia outside the intensive care unit: a case-control study. Am J Infect Control 2014; 42:38.
- Ranjan N, Chaudhary U, Chaudhry D, Ranjan KP. Ventilator-associated pneumonia in a tertiary care intensive care unit: Analysis of incidence, risk factors and mortality. Indian J Crit Care Med 2014; 18:200.
- Charles MP, Kali A, Easow JM, et al. Ventilator-associated pneumonia. Australas Med J 2014; 7:334.
- Wałaszek M, Kosiarska A, Gniadek A, et al. The risk factors for hospital-acquired pneumonia in the Intensive Care Unit. Przegl Epidemiol 2016; 70:15.
- Nakaviroj S, Cherdrungsi R, Chaiwat O. Incidence and risk factors for ventilator-associated pneumonia in the surgical intensive care unit, Siriraj Hospital. J Med Assoc Thai 2014; 97 Suppl 1:S61.
- Markowicz P, Wolff M, Djedaïni K, et al. Multicenter prospective study of ventilator-associated pneumonia during acute respiratory distress syndrome. Incidence, prognosis, and risk factors. ARDS Study Group. Am J Respir Crit Care Med 2000; 161:1942.
- Lewis SC, Li L, Murphy MV, et al. Risk factors for ventilator-associated events: a case-control multivariable analysis. Crit Care Med 2014; 42:1839.
- Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med 2003; 138:494.
- Prod'hom G, Leuenberger P, Koerfer J, et al. Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. A randomized controlled trial. Ann Intern Med 1994; 120:653.
- Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA 2009; 301:2120.
- Eom CS, Jeon CY, Lim JW, et al. Use of acid-suppressive drugs and risk of pneumonia: a systematic review and meta-analysis. CMAJ 2011; 183:310.
- Huang J, Cao Y, Liao C, et al. Effect of histamine-2-receptor antagonists versus sucralfate on stress ulcer prophylaxis in mechanically ventilated patients: a meta-analysis of 10 randomized controlled trials. Crit Care 2010; 14:R194.
- Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35:915.
- Torres A, Serra-Batlles J, Ros E, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 1992; 116:540.
- Orozco-Levi M, Torres A, Ferrer M, et al. Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med 1995; 152:1387.
- 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; 354:1851.
- Smulders K, van der Hoeven H, Weers-Pothoff I, Vandenbroucke-Grauls C. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest 2002; 121:858.
- Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest 1999; 116:1339.
- Muscedere J, Rewa O, McKechnie K, et al. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis. Crit Care Med 2011; 39:1985.
- Hubbard JL, Veneman WL, Dirks RC, et al. Use of endotracheal tubes with subglottic secretion drainage reduces ventilator-associated pneumonia in trauma patients. J Trauma Acute Care Surg 2016; 80:218.
- Mentec H, Dupont H, Bocchetti M, et al. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med 2001; 29:1955.
- McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med 2005; 33:324.
- Montejo JC, Miñambres E, Bordejé L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med 2010; 36:1386.
- Reignier J, Mercier E, Le Gouge A, 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.
- Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007; 334:889.
- Labeau SO, Van de Vyver K, Brusselaers N, et al. Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis 2011; 11:845.
- Price R, MacLennan G, Glen J, SuDDICU Collaboration. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. BMJ 2014; 348:g2197.
- D'Amico R, Pifferi S, Leonetti C, et al. Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials. BMJ 1998; 316:1275.
- Silvestri L, van Saene HK, Casarin A, et al. Impact of selective decontamination of the digestive tract on carriage and infection due to Gram-negative and Gram-positive bacteria: a systematic review of randomised controlled trials. Anaesth Intensive Care 2008; 36:324.
- Roquilly A, Marret E, Abraham E, Asehnoune K. Pneumonia prevention to decrease mortality in intensive care unit: a systematic review and meta-analysis. Clin Infect Dis 2015; 60:64.
- Bonten MJ. Healthcare epidemiology: Ventilator-associated pneumonia: preventing the inevitable. Clin Infect Dis 2011; 52:115.
- Kollef MH, Micek ST. Rational use of antibiotics in the ICU: balancing stewardship and clinical outcomes. JAMA 2014; 312:1403.
- Wunderink RG. Welkommen to our world. Emergence of antibiotic resistance with selective decontamination of the digestive tract. Am J Respir Crit Care Med 2010; 181:426.
- Oostdijk EA, de Smet AM, Blok HE, et al. Ecological effects of selective decontamination on resistant gram-negative bacterial colonization. Am J Respir Crit Care Med 2010; 181:452.
- Food and Agriculture Organization of the United Nations and World Health Organization. Guidelines for the evaluation of probiotics in food. http://www.who.int/foodsafety/fs_management/en/probiotic_guidelines.pdf (Accessed on January 10, 2011).
- Morrow LE, Kollef MH, Casale TB. Probiotic prophylaxis of ventilator-associated pneumonia: a blinded, randomized, controlled trial. Am J Respir Crit Care Med 2010; 182:1058.
- Bo L, Li J, Tao T, et al. Probiotics for preventing ventilator-associated pneumonia. Cochrane Database Syst Rev 2014; :CD009066.
- Zeng J, Wang CT, Zhang FS, et al. Effect of probiotics on the incidence of ventilator-associated pneumonia in critically ill patients: a randomized controlled multicenter trial. Intensive Care Med 2016; 42:1018.
- Kollef MH, Afessa B, Anzueto A, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA 2008; 300:805.
- Tokmaji G, Vermeulen H, Müller MC, et al. Silver-coated endotracheal tubes for prevention of ventilator-associated pneumonia in critically ill patients. Cochrane Database Syst Rev 2015; :CD009201.
- Afessa B, Shorr AF, Anzueto AR, et al. Association between a silver-coated endotracheal tube and reduced mortality in patients with ventilator-associated pneumonia. Chest 2010; 137:1015.
- Roquilly A, Mahe PJ, Seguin P, et al. Hydrocortisone therapy for patients with multiple trauma: the randomized controlled HYPOLYTE study. JAMA 2011; 305:1201.
- Bulger EM, Cuschieri J. Steroids after severe injury: many unanswered questions. JAMA 2011; 305:1242.
- Roberts I, Yates D, Sandercock P, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 2004; 364:1321.
- Steinberg KP, Hudson LD, Goodman RB, et al. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med 2006; 354:1671.
- Bouadma L, Deslandes E, Lolom I, et al. Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit. Clin Infect Dis 2010; 51:1115.
- Klompas M. Ventilator-associated pneumonia: is zero possible? Clin Infect Dis 2010; 51:1123.
- Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol 2011; 32:305.
- Okgün Alcan A, Demir Korkmaz F, Uyar M. Prevention of ventilator-associated pneumonia: Use of the care bundle approach. Am J Infect Control 2016; 44:e173.
- Pneumonia types
- Multidrug resistance
- RISK FACTORS
- Role of gastric pH
- Preventing aspiration
- - Patient positioning
- - Subglottic drainage
- - Gastric volume monitoring
- Decontamination of the digestive tract
- Silver-coated endotracheal tube
- Prevention bundles
- INFORMATION FOR PATIENTS