VENTILATOR ASSOCIATED PNEUMONIA (VAP)

Ventilator Associated Pneumonia (VAP)

[Tara Henley]

[Drexel University]

[18th Febuary 2010]

Ventilator Associated Pneumonia (VAP)

Introduction

Ventilator-associated pneumonia (VAP) is a frequent nosocomial infection. Among critically ill patients, it is the second most common nosocomial infection but is the leading cause of nosocomial morbidity. Development of VAP increases both the duration of mechanical ventilation (MV) and the length of stay in the intensive care unit (leU). Some researchers estimate that the attributable cost per case of VAP is -$12,000. The effect of VAP on mortality is less clear, but the mortality rate attributable to VAP may approach 30%.(Vincent 2004)

Hypothesis

Levofloxacin would not be inferior to imipenem-cilastatin for treating VAP.

Purpose of Study

Recently completed randomized trial compared levofloxacin with imipenem-cilastatin for treating NP. In this study the researcher tried to understand more-detailed information about the efficacy of these agents and the outcomes from this trial involving patients with VAP.

Literature Review

The difference between the two bundles lies in their components. All components of the VAPB directly affect the clinical outcome of reducing VAP. Abbott and colleagues (2006) suggest that HOB elevation, oral care, ventilator tubing condensate, hand hygiene, and glove use are all important interventions in decreasing VAP rate and the number of ventilator days. Similarly, Hatler et al. (2006) propose that HOB elevation, oral care, turning patients from side to side, and sedation vacation can reduce the frequency of VAP rate and the number of ventilator days.

On the other hand, the studies that implemented the ventilator care bundles based on the IHI recommendations all include HOB elevation, sedation vacation, DVT prophylaxis, and peptic ulcer prophylaxis (Crunden et al. 2005; Hampton et al. 2005; Resar et al. 2005; Youngquist et al. 2007). Although VAPB directly relates to VAP reduction, only the HOB elevation and sedation vacations in ventilator care bundles have been shown to have an effect on outcomes for VAP (Resar et al. 2005). Although DVT prophylaxis and peptic ulcer prophylaxis improve the outcomes of mechanically ventilated patients, they do not directly affect the VAP outcomes of patients in the ICU (IHI 2006).

Etiology of VAP

Intubation impedes the body's natural defence against respiratory infections. The placement of an endotracheal tube (ETT) negates effective cough reflexes that protect the airway from invasive pathogens. An ETT prevents mucociliary clearance of secretions and depresses epiglottic reflexes; thus, the entry of virulent bacteria (either from excess secretions or from aspirated esophageal or stomach contents) pools and leaks around the inflated ETT cuff (Vincent 2004) infiltrating the lungs and causing pneumonia.

VAP can occur early or late during a patient's course of intubation and mechanical ventilation. Early onset occurs within 48 to 96 hours of intubation (Pruitt & Jacobs 2006). Most common microorganisms include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Late-onset VAP occurs 5 or more days after intubation. (Vincent 2004)

Staphylococcus aureus, Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter are some of the most prevalent microorganisms reported for late-onset VAP (Pruitt & Jacobs 2006).

Risk Factors

The risk factors associated with VAP include agents that can impair the patient's defence system ...