Prevention of VAP and Ventilator-Associated Conditions
Prevention of VAP and Ventilator-Associated Conditions
Objectives Ventilator-associated pneumonia diagnosis remains a debatable topic. New definitions of ventilator-associated conditions involving worsening oxygenation have been recently proposed to make surveillance of events possibly linked to ventilator-associated pneumonia as objective as possible. The objective of the study was to confirm the effect of subglottic secretion suctioning on ventilator-associated pneumonia prevalence and to assess its concomitant impact on ventilator-associated conditions and antibiotic use.
Design Randomized controlled clinical trial conducted in five ICUs of the same hospital.
Patients Three hundred fifty-two adult patients intubated with a tracheal tube allowing subglottic secretion suctioning were randomly assigned to undergo suctioning (n = 170, group 1) or not (n = 182, group 2).
Main Results During ventilation, microbiologically confirmed ventilator-associated pneumonia occurred in 15 patients (8.8%) of group 1 and 32 patients (17.6%) of group 2 (p = 0.018). In terms of ventilatory days, ventilator-associated pneumonia rates were 9.6 of 1,000 ventilatory days and 19.8 of 1,000 ventilatory days, respectively (p = 0.0076). Ventilator-associated condition prevalence was 21.8% in group 1 and 22.5% in group 2 (p = 0.84). Among the 47 patients with ventilator-associated pneumonia, 25 (58.2%) experienced a ventilator-associated condition. Neither length of ICU stay nor mortality differed between groups; only ventilator-associated condition was associated with increased mortality. The total number of antibiotic days was 1,696 in group 1, representing 61.6% of the 2,754 ICU days, and 1,965 in group 2, representing 68.5% of the 2,868 ICU days (p < 0.0001).
Conclusions: Subglottic secretion suctioning resulted in a significant reduction of ventilator-associated pneumonia prevalence associated with a significant decrease in antibiotic use. By contrast, ventilator-associated condition occurrence did not differ between groups and appeared more related to other medical features than ventilator-associated pneumonia.
The implementation of ventilator-associated pneumonia (VAP) bundle in many ICUs has successfully led to a decrease in VAP rate, today reported to be as low as 1 to 3 VAP/1,000 ventilatory days (VD) in the United States. In Europe, it still ranges between 12 and 18 VAP/1,000 VD. As recently assessed by Klompas, this discrepancy may be due to several factors, including VAP definition. To rely on more objective data, new definitions for surveillance of ventilator-associated events have been recently proposed. In this line of thought, a first step would be to document a worsening oxygenation after a period of at least 2 days of stability or improvement. Worsening oxygenation should be recognized by increased daily minimum positive end-expiratory pressure (PEEP) or FIO2 defining ventilator-associated conditions (VAC).
Antibiotic consumption could be another objective variable. VAP is indeed considered as the main reason for antibiotic prescription within the ICU. A reduction in its prevalence should lead to a decrease in antibiotic consumption assessed by the number of antibiotic days.
Subglottic suctioning has already been shown to substantially decrease VAP rate in several monocentric studies and in one multicenter study. However, it is not yet part of VAP bundle used in many ICUs and not yet recommended by European consensus on VAP prevention. Whether it would still be effective in ICU with already low prevalence of VAP is questionable.
Therefore, the aim of the study was to document the efficacy of subglottic suctioning in all ICUs of a tertiary hospital in which a VAP bundle was already in use for 2 years keeping the old definition of VAP. In addition, the reality of the effect may be confirmed by a concomitant reduction in VAC and related events and also by a global reduction in antibiotic use. The study focused primarily on the reduction of VAP prevalence in ICU, while secondary endpoints were VAC occurrence and antibiotic consumption.
Abstract and Introduction
Abstract
Objectives Ventilator-associated pneumonia diagnosis remains a debatable topic. New definitions of ventilator-associated conditions involving worsening oxygenation have been recently proposed to make surveillance of events possibly linked to ventilator-associated pneumonia as objective as possible. The objective of the study was to confirm the effect of subglottic secretion suctioning on ventilator-associated pneumonia prevalence and to assess its concomitant impact on ventilator-associated conditions and antibiotic use.
Design Randomized controlled clinical trial conducted in five ICUs of the same hospital.
Patients Three hundred fifty-two adult patients intubated with a tracheal tube allowing subglottic secretion suctioning were randomly assigned to undergo suctioning (n = 170, group 1) or not (n = 182, group 2).
Main Results During ventilation, microbiologically confirmed ventilator-associated pneumonia occurred in 15 patients (8.8%) of group 1 and 32 patients (17.6%) of group 2 (p = 0.018). In terms of ventilatory days, ventilator-associated pneumonia rates were 9.6 of 1,000 ventilatory days and 19.8 of 1,000 ventilatory days, respectively (p = 0.0076). Ventilator-associated condition prevalence was 21.8% in group 1 and 22.5% in group 2 (p = 0.84). Among the 47 patients with ventilator-associated pneumonia, 25 (58.2%) experienced a ventilator-associated condition. Neither length of ICU stay nor mortality differed between groups; only ventilator-associated condition was associated with increased mortality. The total number of antibiotic days was 1,696 in group 1, representing 61.6% of the 2,754 ICU days, and 1,965 in group 2, representing 68.5% of the 2,868 ICU days (p < 0.0001).
Conclusions: Subglottic secretion suctioning resulted in a significant reduction of ventilator-associated pneumonia prevalence associated with a significant decrease in antibiotic use. By contrast, ventilator-associated condition occurrence did not differ between groups and appeared more related to other medical features than ventilator-associated pneumonia.
Introduction
The implementation of ventilator-associated pneumonia (VAP) bundle in many ICUs has successfully led to a decrease in VAP rate, today reported to be as low as 1 to 3 VAP/1,000 ventilatory days (VD) in the United States. In Europe, it still ranges between 12 and 18 VAP/1,000 VD. As recently assessed by Klompas, this discrepancy may be due to several factors, including VAP definition. To rely on more objective data, new definitions for surveillance of ventilator-associated events have been recently proposed. In this line of thought, a first step would be to document a worsening oxygenation after a period of at least 2 days of stability or improvement. Worsening oxygenation should be recognized by increased daily minimum positive end-expiratory pressure (PEEP) or FIO2 defining ventilator-associated conditions (VAC).
Antibiotic consumption could be another objective variable. VAP is indeed considered as the main reason for antibiotic prescription within the ICU. A reduction in its prevalence should lead to a decrease in antibiotic consumption assessed by the number of antibiotic days.
Subglottic suctioning has already been shown to substantially decrease VAP rate in several monocentric studies and in one multicenter study. However, it is not yet part of VAP bundle used in many ICUs and not yet recommended by European consensus on VAP prevention. Whether it would still be effective in ICU with already low prevalence of VAP is questionable.
Therefore, the aim of the study was to document the efficacy of subglottic suctioning in all ICUs of a tertiary hospital in which a VAP bundle was already in use for 2 years keeping the old definition of VAP. In addition, the reality of the effect may be confirmed by a concomitant reduction in VAC and related events and also by a global reduction in antibiotic use. The study focused primarily on the reduction of VAP prevalence in ICU, while secondary endpoints were VAC occurrence and antibiotic consumption.
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