S31 infection control and hospital epidemiology october 2008, vol.

29, supplement 1

supplement article: shea/idsa practice recommendation

Strategies to Prevent Ventilator-Associated Pneumonia

in Acute Care Hospitals
Susan E. Coffin, MD, MPH; Michael Klompas, MD; David Classen, MD, MS; Kathleen M. Arias, MS, CIC;
Kelly Podgorny, RN, MS, CPHQ; Deverick J. Anderson, MD, MPH; Helen Burstin, MD; David P. Calfee, MD, MS;
Erik R. Dubberke, MD; Victoria Fraser, MD; Dale N. Gerding, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD;
Keith S. Kaye, MD; Evelyn Lo, MD; Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; Lindsay Nicolle, MD;
David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS;
Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPH

purpose natal and surgical patient populations.5-9 The results of

recent quality improvement initiatives, however, suggest
Previously published guidelines are available that provide that many cases of VAP might be prevented by careful
comprehensive recommendations for detecting and prevent- attention to the process of care.
ing healthcare-associated infections. The intent of this doc-
ument is to highlight practical recommendations in a concise 2. Outcomes associated with VAP
format designed to assist acute care hospitals in implementing a. VAP is a cause of significant patient morbidity and
and prioritizing their ventilator-associated pneumonia (VAP) mortality, increased utilization of healthcare resources, and
prevention efforts. Refer to the Society for Healthcare Epi-
excess cost.10-13
demiology of America/Infectious Diseases Society of America
i. The mortality attributable to VAP may exceed
“Compendium of Strategies to Prevent Healthcare-Associated
10%.14-22
Infections” Executive Summary and Introduction and ac-
ii. Patients with VAP require prolonged periods of
companying editorial for additional discussion.
mechanical ventilation,23 extended hospitalizations,4,11,16
excess use of antimicrobial medications, and increased
section 1: r ationale and statements
direct medical costs.11,13,14
of concer n
1. Occurrence of VAP in acute care facilities. 3. Pathogenesis of and risk factors for VAP
a. VAP is one of the most common infections acquired a. VAP arises when there is bacterial invasion of the
by adults and children in intensive care units (ICUs).1,2 pulmonary parenchyma in a patient receiving mechanical
i. In early studies, it was reported that 10%-20% of ventilation.
patients undergoing ventilation developed VAP.3,4 More- i. Inoculation of the formerly sterile lower respiratory
recent publications report rates of VAP that range from tract typically arises from aspiration of secretions, col-
1 to 4 cases per 1,000 ventilator-days, but rates may onization of the aerodigestive tract, or use of contami-
exceed 10 cases per 1,000 ventilator-days in some neo- nated equipment or medications.24

From the Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (S.E.C.); the Brigham and
Women’s Hospital and Harvard Medical School, Boston (M.K., D.S.Y.), and the Institute for Healthcare Improvement, Cambridge (F.A.G.), Massachusetts;
the University of Utah, Salt Lake City (D.C.); the Association for Professionals in Infection Control and Epidemiology (K.M.A.) and the National Quality
Forum (H.B.), Washington, D.C.; the Loyola University Chicago Stritch School of Medicine (D.N.G.), the Stroger (Cook County) Hospital and the Rush
University Medical Center (R.A.W.), Chicago, the Joint Commission, Oakbrook Terrace (K.P., R.W.), and the Hines Veterans Affairs Medical Center, Hines
(D.N.G.), Illinois; the Duke University Medical Center, Durham, North Carolina (D.J.A., K.S.K.); the Mount Sinai School of Medicine, New York, New
York (D.P.C.); the Washington University School of Medicine, St. Louis, Missouri (E.R.D., V.F., J.M.); the Hackensack University Medical Center, Hackensack
(P.G.) and the University of Medicine and Dentistry–New Jersey Medical School, Newark (P.G.), New Jersey; the Warren Alpert Medical School of Brown
University and Rhode Island Hospital, Providence, Rhode Island (L.A.M.); the David Geffen School of Medicine at the University of California, Los Angeles
(D.A.P.); the Johns Hopkins Medical Institutions and University, Baltimore, Maryland (T.M.P.); the Ann Arbor Veterans Affairs Medical Center and the
University of Michigan Medical School, Ann Arbor, Michigan (S.S.); the Medical University of South Carolina, Charleston (C.D.S.); and the University of
Manitoba, Winnipeg, Canada (E.L., L.N.).
Accepted June 4, 2008; electronically published September 16, 2008.
Infect Control Hosp Epidemiol 2008; 29:S31–S40
䉷 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0005$15.00. DOI: 10.1086/591062
S32 infection control and hospital epidemiology october 2008, vol. 29, supplement 1

ii. Risk factors for VAP include prolonged intuba- ii. Colonization of the aerodigestive tract
tion,25 enteral feeding,26 witnessed aspiration,27 paralytic iii. Use of contaminated equipment
agents,27 underlying illness,7,11,27,28 and extremes of age.28
2. General strategies that have been found to influence the
section 2: strategies to detect vap risk of VAP
a. General strategies
1. Surveillance definition
a. The definition of VAP is perhaps the most subjective i. Conduct active surveillance for VAP.52,53
of the common device-related healthcare-associated infec- ii. Adhere to hand-hygiene guidelines published by
tions.29-32 Most hospital epidemiologists and infection pre- the Centers for Disease Control and Prevention or the
vention and control professionals use the VAP definition World Health Organization.52,53
put forth by the National Healthcare Safety Network, which iii. Use noninvasive ventilation whenever possible.54-61
uses 3 groups of criteria: clinical, radiographic, and iv. Minimize the duration of ventilation.53,62,63
microbiological.33 v. Perform daily assessments of readiness to wean5,50
i. Despite the use of a common definition, significant and use weaning protocols.57,62,64-69
interobserver variability has been noted.34-36 vi. Educate healthcare personnel who care for patients
ii. Factors such as the surveillance strategy, diagnostic undergoing ventilation about VAP.52,53,70,71
techniques, and microbiology and laboratory procedures b. Strategies to prevent aspiration
likely account for some of the differences in VAP rates i. Maintain patients in a semirecumbent position
between different institutions.29 (30⬚-45⬚ elevation of the head of the bed) unless there
are contraindications.28,50,52,53,57,65,72-76
2. Methods for surveillance of VAP (a) Experimental trials have demonstrated that
a. Active surveillance is required to accurately identify backrest elevation is associated with a reduced risk of
patients with VAP.22,37 Case finding by review of adminis- pulmonary aspiration.72,75
trative data alone, such as discharge diagnosis codes, is (b) Multivariable analysis of risk factors associated
inaccurate and lacks both sensitivity and specificity.38,39 with VAP found up to a 67% reduction in VAP among
i. Case finding of VAP is complex as a result of clinical patients maintained in semirecumbency during the
criteria that vary with age and other host factors. first 24 hours of mechanical ventilation.28
ii. The need for review of 2 or more chest radiographs (c) The impact of semirecumbency was confirmed
for patients with underlying pulmonary or cardiac dis- in an observational study50 and a randomized trial.73
ease also contributes to the difficulties in identifying (d) However, recent studies indicate that semire-
patients with VAP. cumbent positioning is rarely maintained77 and may
iii. Gram staining and semiquantitative culture of en- not be associated with a reduced rate of tracheal col-
dotracheal secretions or quantitative culture of speci- onization77 or VAP.78
mens obtained through bronchoalveolar lavage should ii. Avoid gastric overdistention.26,57,79,80
be performed for a patient suspected to have VAP. The iii. Avoid unplanned extubation and reintuba-
question of which method is optimal for specimen col- tion.7,25,52,53
lection of lower respiratory tract secretions for diagnosis iv. Use a cuffed endotracheal tube with in-line or
of VAP is controversial.22,37,40-42 subglottic suctioning.52,57,81-86
iv. Information technology, such as electronic sur- (a) Meta-analysis demonstrated that subglottic se-
veillance tools, can assist in the identification of patients cretion drainage was effective in preventing early-on-
with possible VAP but cannot provide definitive iden- set VAP.85
tification and are not yet widely available.43,44 v. Maintain an endotracheal cuff pressure of at least
20 cm H2O.87
section 3: strategies to prevent vap c. Strategies to reduce colonization of the aerodigestive
1. Existing guidelines and recommendations tract
a. Guidelines to prevent VAP have been published by i. Orotracheal intubation is preferable to nasotracheal
several expert groups and, when fully implemented, im- intubation.
prove patient outcomes and are cost-effective.45-51 (a) Nasotracheal intubation increases the risk of
b. Because few studies have evaluated the prevention of sinusitis,88,89 which may increase the risk for VAP.90,91
VAP in children, the majority of these recommendations ii. Avoid histamine receptor 2 (H2)–blocking agents
stem from studies that were performed in adults. The core and proton pump inhibitors for patients who are not at
recommendations are designed to interrupt the 3 most high risk for developing a stress ulcer or stress
common mechanisms by which VAP develops: gastritis.53,57,76,92
i. Aspiration of secretions (a) Acid-suppressive therapy may increase the col-
 strategies for prevention of vap S33

onization density of the aerodigestive tract with po- I. Basic practices for prevention and monitoring of VAP:
tentially pathogenic organisms. recommended for all acute care hospitals
(b) Seven meta-analyses have yielded inconsistent
A. Education
results regarding the magnitude of risk associated with
the colonization of the aerodigestive tract.93-98 Health-
1. Educate healthcare personnel who care for patients un-
care Infection Control Practices Advisory Committee
dergoing ventilation about VAP, including information about
Guidelines identified the preferential use of sucralfate
the following (A-II):
or H2-blocking agents as an unresolved issue.52
a. Local epidemiology
(c) A single retrospective study of children under-
b. Risk factors
going ventilation found that the rate of VAP did not
c. Patient outcomes
vary according to the strategy used to prevent gastro-
intestinal bleeding.99
2. Educate clinicians who care for patients undergoing
iii. Perform regular oral care57,100-103 with an antiseptic
ventilation about noninvasive ventilatory strategies (B-III).
solution.101,104-108 The optimal frequency for oral care is
unresolved. B. Surveillance of VAP
d. Strategies to minimize contamination of equipment
used to care for patients receiving mechanical ventilation 1. Perform direct observation of compliance with VAP-
i. Use sterile water to rinse reusable respiratory specific process measures (B-III).
equipment.52 a. VAP-specific process measures include hand hygiene,
ii. Remove condensate from ventilatory circuits. Keep bed position, daily sedation interruption and assessment
the ventilatory circuit closed during condensate of readiness to wean, and regular oral care.
removal.52,53,57,109 b. Use structured observation tools at regularly sched-
iii. Change the ventilatory circuit only when visibly uled intervals.
soiled or malfunctioning.21,52,110-114
iv. Store and disinfect respiratory therapy equipment 2. Conduct active surveillance for VAP and associated pro-
properly.52 (See the Appendix.) cess measures in units that care for patients undergoing ven-
tilation who are known or suspected to be at high risk for
section 4 : recommendations f or VAP on the basis of risk assessment (A-II).
implementing prevention and a. Collect data that will support the identification of
monitoring strategies patients with VAP and calculation of VAP rates (ie, the
number of VAP cases and number of ventilator-days for
Recommendations for preventing and monitoring VAP are all patients who are undergoing ventilation and in the pop-
summarized in the following section. They are designed to ulation being monitored).
assist acute care hospitals in prioritizing and implementing
their VAP prevention efforts. Criteria for grading the strength C. Practice
of recommendation and quality of evidence are described in
the Table. 1. Implement policies and practices for disinfection, ster-

table. Strength of Recommendation and Quality of Evidence

Category/grade Definition
Strength of recommendation
A Good evidence to support a recommendation for use
B Moderate evidence to support a recommendation for use
C Poor evidence to support a recommendation
Quality of evidence
I Evidence from x1 properly randomized, controlled trial
II Evidence from x1 well-designed clinical trial, without
randomization; from cohort or case-control analytic
studies (preferably from 11 center); from multiple
time series; or from dramatic results from uncontrolled
experiments
III Evidence from opinions of respected authorities, based
on clinical experience, descriptive studies, or reports of
expert committees
note. Adapted from the Canadian Task Force on the Periodic Health Examination.115
S34 infection control and hospital epidemiology october 2008, vol. 29, supplement 1

ilization, and maintenance of respiratory equipment that are tient education are accountable for ensuring that appropriate
aligned with evidence-based standards (eg, guidelines from training and educational programs to prevent VAP are de-
the Centers for Disease Control and Prevention and profes- veloped and provided to personnel, patients, and families.
sional organizations) (A-II).52
a. See the Appendix for a list of recommended practices. 8. Personnel from the infection prevention and control
program, the laboratory, and information technology de-
2. Ensure that all patients (except those with medical con- partments are responsible for ensuring that systems are in
traindications) are maintained in a semirecumbent position place to support the surveillance program.
(B-II).
II. Special approaches for the prevention of VAP
3. Perform regular antiseptic oral care in accordance with Perform a VAP risk assessment. These special approaches are
product guidelines (A-I). recommended for use in locations and/or populations within
the hospital that have unacceptably high VAP rates despite
4. Provide easy access to noninvasive ventilation equip- implementation of the basic VAP prevention procedures listed
ment and institute protocols to promote the use of nonin- above.
vasive ventilation (B-III).
1. Use an endotracheal tube with in-line and subglottic
D. Accountability suctioning for all eligible patients (B-II).

1. The hospital’s chief executive officer and senior man- 2. Ensure that all ICU beds used for patients undergoing
agement are responsible for ensuring that the healthcare sys- ventilation have a built-in tool to provide continuous mon-
tem supports an infection prevention and control program itoring of the angle of incline (B-III).
to effectively prevent VAP.
III. Approaches that should not be considered a routine
2. Senior management is accountable for ensuring that an part of VAP prevention
adequate number of trained personnel are assigned to the
infection prevention and control program. 1. Do not routinely administer intravenous immunoglob-
ulin,52 white-cell–stimulating factors (filgrastim or sargra-
3. Senior management is accountable for ensuring that mostim),52 enteral glutamine,52 or chest physiotherapy52,116 (A-
healthcare personnel, including licensed and nonlicensed per- III).
sonnel, are competent to perform their job responsibilities.
2. Do not routinely use rotational therapy with kinetic or
4. Direct healthcare providers (such as physicians, nurses, continuous lateral rotational therapy beds (B-II).52,117
aides, and therapists) and ancillary personnel (such as house-
keeping and equipment-processing personnel) are responsible 3. Do not routinely administer prophylactic aerosolized or
for ensuring that appropriate infection prevention and con- systemic antimicrobials (B-III).2,52,118
trol practices are used at all times (including hand hygiene,
standard and isolation precautions, cleaning and disinfection IV. Unresolved issues
of equipment and the environment, aseptic techniques when 1. Avoidance of H2 antagonist or proton pump inhibitors
suctioning secretions and handling respiratory therapy equip- for patients who are not at high risk for developing gastro-
ment, patient positioning, sedation and weaning protocols, intestinal bleeding76,93,94,98,119-122
and oral care).
2. Selective digestive tract decontamination for all patients
5. Hospital and unit leaders are responsible for holding undergoing ventilation123-128
their personnel accountable for their actions.
3. Use of antiseptic-impregnated endotracheal tubes129,130
6. The person who manages the infection prevention and
control program is responsible for ensuring that an active 4. Intensive glycemic control131-134
program to identify VAP is implemented, that data on VAP
are analyzed and regularly provided to those who can use the section 5 : p erformance measures
information to improve the quality of care (eg, unit staff,
I. Internal reporting
clinicians, and hospital administrators), and that evidence-
based practices are incorporated into the program. These performance measures are intended to support internal
hospital quality improvement efforts and do not necessarily
7. Personnel responsible for healthcare personnel and pa- address external reporting needs.
 strategies for prevention of vap S35

The process and outcome measures suggested here are de- be adjusted on the basis of compliance rates (eg, as com-
rived from published guidelines, other relevant literature, and pliance improves, less frequent observations may be
the opinions of the authors. Report both process and outcome needed).
measures to senior hospital leadership, nursing leadership, b. Preferred measure of assessment of compliance with
and clinicians who care for patients at risk for VAP. antiseptic oral care
i. Numerator: number of patients undergoing ven-
A. Process measures tilation with daily documentation of regular oral care
according to product instructions.
1. Compliance with hand-hygiene guidelines for all cli- ii. Denominator: number of patients undergoing
nicians who deliver care to patients undergoing ventilation ventilation.
a. Collect data on a sample of healthcare personnel from iii. Multiply by 100 so that the measure is expressed
all disciplines who provide hands-on care to patients un- as a percentage.
dergoing ventilation, including physicians, nurses, respi-
ratory therapists, and radiology technicians. Perform ob- 4. Compliance with semirecumbent positioning for all el-
servations at regular intervals (eg, 1 set of measurements igible patients
per week). The frequency of observations can be adjusted a. Assessment should be performed for all patients cur-
on the basis of compliance rates (eg, as compliance im- rently undergoing ventilation, by direct observation of the
proves, less frequent observations may be needed). position of the head of bed. Perform assessments at regular
b. Preferred measure for hand-hygiene compliance intervals (eg, 1 set of measurements per week). The fre-
i. Numerator: number of observed appropriate hand- quency of observations can be adjusted on the basis of
hygiene episodes performed by healthcare personnel. compliance rates (eg, as compliance improves, less frequent
ii. Denominator: number of observed opportunities observations may be needed).
for hand hygiene. b. Preferred measure of assessment of semirecumbent
iii. Multiply by 100 so that the measure is expressed positioning compliance
as a percentage. i. Numerator: number of patients undergoing ven-
tilation who are in a semirecumbent position (30⬚-45⬚
2. Compliance with daily sedation interruption and as- elevation of the head of the bed) at the time of
sessment of readiness to wean observation.
a. Assessment should be performed by chart review of ii. Denominator: number of patients undergoing ven-
a sample of all patients currently undergoing ventilation. tilation who are eligible to be in a semirecumbent
Evidence of daily documentation on the patient’s chart, position.
bedside paperwork, or electronic medical record of a se- iii. Multiply by 100 so that the measure is expressed
dation interruption and assessment of readiness to wean as a percentage.
should be present unless clinically contraindicated. Per-
form assessments at regular intervals (eg, 1 set of mea- B. Outcome measures
surements per week). The frequency of observations can Perform ongoing surveillance of the incidence density of
be adjusted on the basis of compliance rates (eg, as com- VAP on units that care for patients undergoing ventilation
pliance improves, less frequent observations may be who are known or suspected to be at high risk for VAP, to
needed). permit longitudinal assessment of process of care.
b. Preferred measure of compliance with sedation in-
terruption and assessment of readiness to wean 1. Incidence density of VAP, reported as the number of
i. Numerator: number of patients undergoing ven- episodes of VAP per 1,000 ventilator-days.
tilation with daily documentation of consideration of a. Preferred measure of VAP incidence density
sedation interruption and assessment of readiness to i. Numerator: number of patients undergoing me-
wean or contraindication. chanical ventilation who have VAP, defined using Na-
ii. Denominator: number of patients undergoing tional Healthcare Safety Network definitions.
ventilation. ii. Denominator: number of ventilator-days.
iii. Multiply by 100 so that the measure is expressed iii. Multiply by 1,000 so that the measure is expressed
as a percentage. as cases per 1,000 ventilator-days.

II. External reporting

3. Compliance with regular antiseptic oral care
a. Assessment should be performed by chart review of There are many challenges in providing useful information
a sample of all patients currently undergoing ventilation. to consumers and other stakeholders while preventing un-
Perform assessments at regular intervals (eg, 1 set of mea- intended adverse consequences of public reporting of health-
surements per week). The frequency of observations can care-associated infections.135 Recommendations for public re-
S36 infection control and hospital epidemiology october 2008, vol. 29, supplement 1

porting of healthcare-associated infections have been b. Whenever possible, use steam sterilization or high-
provided by the Hospital Infection Control Practices Advisory level disinfection by wet heat pasteurization at tempera-
Committee,136 the Healthcare-Associated Infection Working tures higher than 70⬚C (158⬚F) for 30 minutes for repro-
Group of the Joint Public Policy Committee,137 and the Na- cessing semicritical equipment or devices (ie, items that
tional Quality Forum.138 come into direct or indirect contact with mucous mem-
Because of the difficulties in diagnosing VAP,30 the validity branes of the lower respiratory tract). Use low-temperature
of comparing VAP rates between facilities is poor, and external sterilization methods (as approved by the Office of Device
reporting of rates of VAP is not recommended.29 Evaluation, Center for Devices and Radiologic Health, US
A. State and federal requirements Food and Drug Administration) for equipment or devices
that are heat or moisture sensitive. After disinfection, pro-
1. Hospitals in states that have mandatory reporting re- ceed with appropriate rinsing, drying, and packaging, tak-
quirements for VAP must collect and report the data required ing care not to contaminate the disinfected items (category
by the state. IA).
2. For information on local requirements, check with your c. Preferentially use sterile water to rinse reusable sem-
state or local health department. icritical respiratory equipment and devices when rinsing is
needed after chemical disinfection. If this is not feasible,
B. External quality initiatives rinse the device with filtered water (ie, water that has been
through a 0.2-mm filter) or tap water, and then rinse with
1. Hospitals that participate in external quality initiatives isopropyl alcohol and dry with forced air or in a drying
or state programs must collect and report the data required cabinet (category IB).
by the initiative or the program. d. Adhere to provisions in the US Food and Drug Ad-
ministration’s enforcement document for single-use de-
vices that are reprocessed by third parties (category IC).
acknowledgments
For Potential Conflicts of Interest statements and information on financial 2. Mechanical ventilators
support, please see the Acknowledgments in the Executive Summary, on page a. Do not routinely sterilize or disinfect the internal
S20 of this supplement.
machinery of mechanical ventilators (category II).

appendix 3. Breathing circuits, humidifiers, and heat-moisture

exchangers
sterilization, d isinfection, and a. Do not, on the basis of duration of use, routinely
maintenance of respiratory change the breathing circuit (ie, ventilator tubing and ex-
equipment, b ased on healthcare halation valve and the attached humidifier) that is in use
infection c ontrol practices by an individual patient. Change the circuit when it is
advisory c ommittee visibly soiled or mechanically malfunctioning (category
recommendations IA).
b. Periodically drain and discard any condensate that
The Healthcare Infection Control Practices Advisory Com- collects in the tubing of a mechanical ventilator, taking
mittee52 system for categorization of recommendations is as precautions not to allow condensate to drain toward the
follows: patient (category IB).
Category IA: Strongly recommended for implementation c. Wear gloves to perform the above procedure or han-
and strongly supported by well-designed experimental, dle the fluid (category IB).
clinical, or epidemiologic studies. d. Decontaminate hands with soap and water (if hands
Category IB: Strongly recommended for implementation are visibly soiled) or with an alcohol-based hand rub, after
and supported by some experimental, clinical, or epi- performing the procedure or handling the fluid (category
demiologic studies and a strong theoretical rationale. IA).
Category IC: Required for implementation, as mandated e. Use sterile (not distilled nonsterile) water to fill bub-
by federal or state regulation or standard. bling humidifiers (category II).
Category II: Suggested for implementation and supported f. Change a heat-moisture exchanger that is in use by
by suggestive clinical or epidemiological studies or a a patient when it malfunctions mechanically or becomes
theoretical rationale.
visibly soiled (category II).
1. General measures g. Do not routinely change more frequently than every
a. Thoroughly clean all respiratory equipment to be 48 hours a heat-moisture exchanger that is in use by a
sterilized or disinfected (category IA). patient (category II).
 strategies for prevention of vap S37

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