Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update Author(s): Michael Klompas, MD, MPH; Richard Branson, MSc, RRT; Eric C. Eichenwald, MD; Linda R. Greene, RN, MPS, CIC; Michael D. Howell, MD, MPH; Grace Lee, MD; Shelley S. Magill, MD, PhD; Lisa L. Maragakis, MD, MPH; Gregory P. Priebe, MD; Kathleen Speck, MPH; Deborah S. Yokoe, MD, MPH; Sean M. Berenholtz, MD, MHS Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 8 (August 2014), pp. 915-936 Stable URL: .
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The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaboratingwith JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology. This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM infection control and hospital epidemiology august 2014, vol. 35, no. 8 Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals: 2014 Update
Michael Klompas, MD, MPH;1,2 Richard Branson, MSc, RRT;3 Eric C. Eichenwald, MD;4
Linda R. Greene, RN, MPS, CIC;5 Michael D. Howell, MD, MPH;6 Grace Lee, MD;1,7
Shelley S. Magill, MD, PhD;8 Lisa L. Maragakis, MD, MPH;9 Gregory P. Priebe, MD;2,7,10
Kathleen Speck, MPH;11 Deborah S. Yokoe, MD, MPH;2 Sean M. Berenholtz, MD, MHS11,12,13
surveillance definitions are subjective and nonspecific.
Historically, 10%–20% of ventilated patients have de- Previously published guidelines are available that provide veloped VAP. More recent reports suggest much lower comprehensive recommendations for detecting and prevent- rates, but it is unclear to what extent these lower rates ing healthcare-associated infections (HAIs). The intent of this reflect better care versus stricter application of subjec- document is to highlight practical recommendations in a con- tive surveillance criteria.3,4 Notwithstanding surveil- cise format to assist acute care hospitals in implementing and lance rates that hover near zero, clinical surveys suggest prioritizing strategies to prevent ventilator-associated pneu- that 5%–15% of ventilated patients still develop nos- monia (VAP) and other ventilator-associated events (VAEs) ocomial pneumonias.5-9 and to improve outcomes for mechanically ventilated adults, B. Patients on mechanical ventilation are at risk for a va- children, and neonates. This document updates "Strategies riety of serious complications in addition to pneumo- to Prevent Ventilator-Associated Pneumonia in Acute Care nia. These include acute respiratory distress syndrome, Hospitals," published in 2008.1 This expert guidance docu- pneumothorax, pulmonary embolism, lobar atelectasis, ment is sponsored by the Society for Healthcare Epidemiology and pulmonary edema. The Centers for Disease Control of America (SHEA) and is the product of a collaborative effort and Prevention (CDC) released new surveillance defi- led by SHEA, the Infectious Diseases Society of America nitions for VAE designed to make surveillance more (IDSA), the American Hospital Association (AHA), the As- objective and to expand surveillance from VAP alone sociation for Professionals in Infection Control and Epide- to include additional serious complications of mechan- miology (APIC), and The Joint Commission, with major con- ical ventilation (see section 2). VAE definitions include tributions from representatives of a number of organizations criteria for ventilator-associated conditions (VACs), and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to (IVACs), possible pneumonia, and probable pneumo- the 2014 updates.2 nia. Approximately 5%–10% of mechanically ventilated patients develop VAEs.10-16 II. VAP and other complications of mechanical ventilation are detrimental to patients and increase costs I. Patients on mechanical ventilation are at high risk for VAP A. The attributable mortality of VAP is estimated to be and other complications approximately 10% but varies considerably for different A. The true incidence of VAP is difficult to determine since kinds of patients.17-20 Affiliations: 1. Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; 2. De- partment of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; 3. Department of Surgery, University of Cincinnati, Ohio; 4. Division ofNeonatal-Perinatal Medicine, University of Texas Medical School at Houston, Houston, Texas; 5. Highland Hospital, University of Rochester Medical CenterAffiliate, Rochester, New York; 6. Department of Medicine, University of Chicago, Chicago, Illinois; 7. Department of Medicine, Boston Children's Hospital,Boston, Massachusetts; 8. Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; 9. Department ofMedicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; 10. Department of Anesthesiology, Perioperative and Pain Medicine, BostonChildren's Hospital, Boston, Massachusetts; 11. Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine,Baltimore, Maryland; 12. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; 13. Department of Health Policyand Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
Received April 14, 2014; accepted April 16, 2014; electronically published July 16, 2014.
Infect Control Hosp Epidemiol 2014;35(8):915-936䉷 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3508-0001$15.00. DOI: 10.1086/677144 This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM infection control and hospital epidemiology august 2014, vol. 35, no. 8 B. Both VAP and VAC extend patients' duration of me- unit (ICU) and the hospital, and increased hospital chanical ventilation, increase intensive care and hospital mortality.10-13 Early data suggest that VACs may be length of stay, and increase mortality risk.11,14-16,20,21 preventable.14,42 Surveillance using these definitions They are also associated with increased use of anti- is efficient and potentially automatable.10,11,15 b. The VAE surveillance framework includes 3 defi- C. VAP increases direct medical costs.21 Excess costs at- nition tiers. These definitions are briefly summa- tributable to VAC have not been quantified.
rized below, but readers are advised to consult theCDC's surveillance protocol for comprehensive (a) VAC is defined by greater than or equal to 2 I. Despite VAP's clinical importance, our ability to conduct days of stable or decreasing daily minimum accurate VAP surveillance is very limited.
positive end expiratory pressure (PEEP) or A. VAP is usually defined by clinical, radiographic, and mi- daily minimum fraction of inspired oxygen crobiological criteria. These signs are neither sensitive (Fio ) followed by an increase in daily min- nor specific relative to histopathology.22-25 These criteria imum PEEP greater than or equal to 3 cm of are also very subjective, leading to substantial interob- H O or daily minimum Fio greater than or server variability.8,9,26-29 Administrative data are similarly equal to 0.20 points sustained for greater than inaccurate.7,30-32 Improvements in VAP rates do not re- or equal to 2 calendar days.
liably correlate with improvements in outcomes.33,34 1. The weaknesses of traditional VAP surveillance def- (a) IVAC is triggered by the presence of possible initions limit their utility for measuring the impact infection indicators concurrent with VAC of care improvement programs and for benchmark- onset, namely, an abnormal temperature (be- ing quality of care between different healthcare fa- low 36⬚C or above 38⬚C) or white blood cell count (less than or equal to 4,000 or greater II. CDC's VAE framework than or equal to 12,000 cells/mm3) and 1 or A. The CDC convened representatives from critical and more new antibiotic starts that continue for respiratory care, infectious diseases, healthcare epide- greater than or equal to 4 days.
miology, and infection prevention professional societies iii. Possible VAP and probable VAP in 2011–2012 to develop a new approach to surveillance (a) Possible VAP is defined as Gram stain evi- for mechanically ventilated patients in an attempt to dence of purulent pulmonary secretions or overcome some of the limitations of traditional VAP a pathogenic pulmonary culture in a patient with IVAC. Probable VAP is defined as Gram 1. The working group recommended the following: stain evidence of purulence plus quantitative a. Developing new definitions based on objective, quantitative criteria to increase the reliability, re- or semiquantitative growth of a pathogenic producibility, comparability, and efficiency of organism beyond specified thresholds. Prob- able VAP can also be triggered by positive b. Broadening the focus of surveillance from pneu- tests for respiratory viruses, Legionella spe- monia alone to complications of mechanical ven- cies, pleural fluid cultures, and suggestive tilation in general. This simultaneously sidesteps histopathology with or without an abnormal VAP definitions' poor specificity and emphasizes Gram stain result.
the importance of preventing all complications of iv. VAC and IVAC were developed to be appro- mechanical ventilation, not just pneumonia.
priate for public reporting; however, further evi- 2. The CDC and the working group utilized emerging dence is needed of their preventability and research on objective surveillance definitions to de- comparability between institutions before rec- velop VAE definitions for adults.10-13,40,41 ommending their adoption for public reporting a. Objective definitions predicated on sustained in- or benchmarking.
creases in ventilator settings after a period of sta- v. Possible and probable VAP were developed for bility detect a range of clinically significant events, healthcare facilities to use for internal quality including VAP, pulmonary edema, acute respira- improvement purposes only. They are not suit- tory distress syndrome, and atelectasis.10,12 They able for public reporting or benchmarking be- consistently predict poor patient outcomes, in- cause clinicians and hospitals vary widely in cluding prolonged mechanical ventilation, in- when and how they acquire and process pul- creased length of stay in both the intensive care monary specimens from ventilated patients.
This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM strategies to prevent vap: 2014 update vi. VAE definitions were designed for adult pa- lung injury. Qualitative analyses suggest that most VACs tients. More data are needed to inform whether are due to pneumonia, pulmonary edema, atelectasis, and how VAE can be adapted for surveillance and acute respiratory distress syndrome.10,12,15 Interven- in children and neonates.
tions that target these complications in particular and III. Recommended surveillance strategies interventions designed to shorten the duration of me- A. Hospitals are advised to conduct active surveillance for chanical ventilation in general may therefore be effective VAE, using CDC definitions and surveillance proto- strategies to lower VAE rates. These could include min- cols.43 The CDC's VAE module requires surveillance for imizing the use of sedatives, paired daily spontaneous all definition tiers (VAC, IVAC, possible VAP, and prob- awakening and breathing trials, early mobility, endo- tracheal tubes with subglottic secretion drainage ports, 1. Infection preventionists should work with their crit- low tidal volume ventilation, intermittent recruitment ical care, respiratory therapy, and/or information maneuvers, conservative fluid management, and re- technology staff to develop efficient means to gather strictive transfusion thresholds.46-54 Studies evaluating and aggregate ventilator data (daily minimum PEEP the impact of these and other interventions on VAE and daily minimum Fio ) from all patients ventilated rates are needed.
for greater than or equal to 4 days. Temperature, C. Until studies of the best strategies to prevent all VAEs white blood cell count, and antibiotic exposure data are published, the existing VAP prevention literature are needed only for the subset of patients who fulfill is the best available guide to improving outcomes for VAC criteria to determine if they fulfill IVAC criteria.
ventilated patients. Given the uncertainty surrounding Pulmonary specimen Gram stains and microbiology the accuracy and reproducibility of VAP diagnoses, test results are required only for the subset of patients however, we prioritize VAP interventions that have who meet IVAC criteria to determine if they fulfill been shown to improve objective outcomes, such as possible or probable VAP criteria.
duration of mechanical ventilation, intensive care or 2. Organizing daily ventilator data into "line lists" for hospital length of stay, mortality, and/or costs in ran- every patient, with 1 row of data per patient per cal- domized controlled trials. In addition, the potential endar day, facilitates VAC detection by allowing the benefits of different interventions are balanced against surveyor to vertically scan daily ventilator settings to their feasibility, costs, and potential harm. Recent re- look for sustained increases that cross the threshold views using this framework informed our recom- for VAC.44 Surveyors can also enter raw data into the CDC's online "VAE calculator" to assist with case iden-tification .
a. The VAE definitions are amenable to partial or complete automation using electronic data. Facil- Interventions that improve objective outcomes with little risk ities seeking to automate VAE detection should of harm are classified as basic practices that are suitable for work with their information technology personnel all hospitals. We also recommend interventions that are out- and/or electronic health record vendor(s).
come neutral but cost saving. Interventions that improve ob-jective outcomes but carry some risk of harm and interven- tions that lower VAP rates but for which insufficient data exist to determine their impact on objective outcomes areclassified as special approaches. Hospitals can consider adopt- I. Framework for evaluating and prioritizing interventions ing special approaches if their VAE rates do not improve A. Although VAE is now the CDC's recommended sur- despite high performance rates on basic practices. Interven- veillance metric for ventilated patients, almost all of the tions that improve neither VAP rates nor objective outcomes existing literature on VAP prevention is based on tra- are not recommended. The quality-of-evidence rating scheme ditional VAP definitions rather than VAE definitions.
is summarized in Table 1. Recommended strategies are sum- There are no data at present on the impact of traditional marized in Table 2 for adults, in Table 3 for preterm neonates, VAP prevention strategies on "probable pneumonias" and in Table 4 for infants and children.
(the closest proxy for VAP in the VAE framework), andthere are very little data regarding their impact on VAC and IVAC.14,45 Of note, VAC and IVAC intentionally flagmore than just pneumonia; hence, interventions di- I. Basic practices to prevent VAP and other VAEs in adult rected solely against pneumonia may not be sufficient patients: interventions with little risk of harm that decrease to reduce VAE rates.
duration of mechanical ventilation, length of stay, mor- B. VAC may be a surveillance marker for nosocomial acute tality, and/or costs This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM infection control and hospital epidemiology august 2014, vol. 35, no. 8 Grading of the Quality of Evidence Highly confident that the true effect lies close to that of the estimated size and direction of the effect. Evidence is rated as high quality when there is a wide range of studies with no majorlimitations, there is little variation between studies, and the summary estimate has a narrowconfidence interval.
The true effect is likely to be close to the estimated size and direction of the effect, but there is a possibility that it is substantially different. Evidence is rated as moderate quality when thereare only a few studies and some have limitations but not major flaws, there is some variationbetween studies, or the confidence interval of the summary estimate is wide.
The true effect may be substantially different from the estimated size and direction of the effect.
Evidence is rated as low quality when supporting studies have major flaws, there is importantvariation between studies, the confidence interval of the summary estimate is very wide, orthere are no rigorous studies, only expert consensus.
Based on Grades of Recommendation, Assessment, Development, and Evaluation (GRADE)239 and the Canadian Task Force on Preventive Health Care.240 A. Avoid intubation if possible mitigated the potential benefits of sedative inter- 1. Use noninvasive positive pressure ventilation (NIPPV) ruption in this trial.65 whenever feasible (quality of evidence: I).
3. Assess readiness to extubate once a day (spontaneous a. NIPPV can be beneficial for patients with acute breathing trials) in patients without contraindications hypercarbic or hypoxemic respiratory failure sec- (quality of evidence: I).47,66-68 ondary to chronic obstructive pulmonary disease a. Daily spontaneous breathing trials are associated or cardiogenic congestive heart failure.57-59 NIPPV with extubation 1–2 days earlier compared with for these indications may decrease VAP risk, shorten the duration of mechanical ventilation, de- 4. Pair spontaneous breathing trials with spontaneous crease length of stay, and lower mortality rates awakening trials (quality of evidence: I).48 compared with invasive ventilation. Use caution a. Patients are more likely to pass a spontaneous when considering NIPPV to manage impaired con- breathing trial and be extubated if they are max- sciousness, acute lung injury, acute respiratory dis- imally awake at the time of the breathing trial.
tress syndrome, severe hypoxemia, and severe ac- C. Maintain and improve physical conditioning idemia or when continuing NIPPV for patients 1. Provide early exercise and mobilization (quality of whose dyspnea or gas exchange fails to rapidly re- evidence: II).
spond to NIPPV. Use of NIPPV for these indica- a. Early exercise and mobilization speed extubation, tions may delay intubation and increase harm, in- decrease length of stay, and increase the rate of cluding death.59,60 return to independent function.49,70-77 B. Minimize sedation b. Financial modeling suggests that early mobility 1. Manage ventilated patients without sedatives when- programs may be cost saving.78 ever possible (quality of evidence: II).46 D. Minimize pooling of secretions above the endotracheal a. Preferentially use agents and strategies other than benzodiazepines to manage agitation, such as an- 1. Provide endotracheal tubes with subglottic secretion algesics for patients in pain, reassurance, antipsy- drainage ports for patients likely to require greater than chotics, dexmedetomidine, and propofol.61 48 or 72 hours of intubation (quality of evidence: II).
2. Interrupt sedation once a day (spontaneous awak- a. Intermittent and continuous drainage of subglottic ening trials) for patients without contraindications secretions has been studied in 13 randomized con- (quality of evidence: I).62,63 trolled trials. On meta-analysis, the use of endotra- a. Two randomized controlled trials found that daily cheal tubes with subglottic drainage reduced VAP sedative interruptions decreased net sedative ex- rates by 55%, mean duration of mechanical venti- posures and reduced the average duration of me- lation by 1.1 days, and intensive care length of stay chanical ventilation by 2–4 days.48,62 A third trial by 1.5 days.50 There was no impact on hospital length found no impact on duration of mechanical ven- of stay or mortality. One study found that subglottic tilation but used substantially higher doses of ben- secretion drainage was associated with less antibiotic zodiazepines compared with the first 2 trials and utilization, while a second did not.79,80 observed an increase in sedative use in the seda- b. Endotracheal tubes with subglottic secretion drain- tion-interruption group.64 These factors may have age may be cost saving.81,82 This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM strategies to prevent vap: 2014 update c. Reductions in duration of mechanical ventilation a. Selective decontamination of the oropharynx with with subglottic secretion drainage appear to be lim- topical antibiotics or of the oropharynx and di- ited to patients expected to require greater than gestive tract with a combination of topic, oral, and 48–72 hours of mechanical ventilation.83 Endotra- parenteral antibiotics decreased mortality rates by cheal tubes with subglottic secretion drainage ports 14% and 17%, respectively, in a large cluster ran- are therefore recommended only as a basic practice domized trial conducted in the Netherlands.95 for patients likely to require greater than 48–72 b. This strategy has not yet been adopted by North hours of intubation. Identifying these patients in American centers, however, due to fear that it advance can be very difficult. Patients requiring might increase the risk of antibiotic-resistant in- emergency intubation in the hospital and preop- fections, including Clostridium difficile infections, erative patients at risk for prolonged mechanical especially in centers with high baseline rates of ventilation are reasonable candidates.
antimicrobial-resistant organisms. Most studies to d. Extubating patients to place a subglottic secretion date do not indicate an elevated short-term risk drainage endotracheal tube is not recommended.
for antimicrobial resistance, but long-term studies E. Elevate the head of the bed are lacking.99,100 Hospitals with high baseline rates 1. Elevate the head of the bed to 30⬚–45⬚ (quality of of antibiotic resistance are advised to await the evidence: III).
results of long-term studies of digestive decontam- a. Elevating the head of the bed has been evaluated ination in high-resistance environments before in only 3 randomized controlled trials enrolling 337 routinely adopting this strategy.
patients altogether.84-86 One trial reported a 76% B. Interventions that may lower VAP rates but for which decrease in VAP rates, whereas the other 2 found there are insufficient data at present to determine their no difference in VAP rates. Of note, the larger of impact on duration of mechanical ventilation, length the 2 negative studies achieved minimal difference of stay, and mortality in head-of-bed elevation between the intervention 1. Perform oral care with chlorhexidine (quality of evi- and control groups, thereby limiting this study's capacity to evaluate the effect of head-of-bed ele- a. Oral care with chlorhexidine has been studied in vation on VAP or other outcomes.85 Nonetheless, at least 16 randomized controlled trials and 9 meta- a meta-analysis pooling these 3 studies did find a analyses to date.98,101-108 The benefits of oral care significant impact on VAP.87 In addition, enteral with chlorhexidine appear to be most pronounced feeding in the supine position substantially in- in preventing postoperative respiratory tract infec- creases the risk of developing VAP.84 tions in cardiac-surgery patients.108-110 The data for b. There are insufficient data at present to determine non-cardiac-surgery patients are more equivocal.
the impact of head-of-bed elevation on duration Meta-analyses suggest that oral care with chlor- of mechanical ventilation or mortality, but given hexidine can reduce pneumonia rates in this pop- the simplicity, ubiquity, minimal risk, lack of cost, ulation by 10%–30%; however, there is no apparent and potential benefit of this intervention we clas- impact on average duration of mechanical venti- sify it as a basic practice while we await further lation, intensive care length of stay, or mor- F. Maintain ventilator circuits b. Routine oral care without chlorhexidine may be 1. Change the ventilator circuit only if visibly soiled or indicated for reasons other than VAP prevention.
malfunctioning (quality of evidence: I).
2. Administer prophylactic probiotics (quality of evi- a. Changing the ventilator circuit as needed rather than on a fixed schedule has no impact on VAP a. Four meta-analyses of randomized controlled trials rates or patient outcomes but decreases costs.88-91 have found an association between probiotics and 2. Follow CDC/Healthcare Infection Control Practices lower VAP rates.111-114 Three of the meta-analyses Advisory Committee guidelines for sterilization and reported on length of stay and mortality. Two found disinfection of respiratory care equipment (quality of a positive impact on intensive care length of stay, while the third did not.111,112,114 None detected a sig- II. Special approaches nificant impact on mortality rates. Probiotics should A. Interventions that decrease duration of mechanical ven- not be used in patients with compromised immune tilation, length of stay, and/or mortality but for which systems or gastrointestinal diseases that increase the insufficient data on possible risks are available risk of gut translocation. There are multiple case 1. Use selective decontamination of the oropharynx to reports of fungemia or bacteremia in patients ad- decrease the microbial burden of the aerodigestive ministered probiotics and case reports of aerosol tract (quality of evidence: I).93-98 transmission of probiotics within ICUs.115-119 This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM infection control and hospital epidemiology august 2014, vol. 35, no. 8 Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Adult Patients Good evidence that the intervention Use noninvasive positive pressure ventilation in decreases the average duration of mechanical ventilation, length of Manage patients without sedation whenever possible46,61 stay, mortality, and/or costs; benefits Interrupt sedation daily62 likely outweigh risks Assess readiness to extubate daily47,66-68 Perform spontaneous breathing trials with sedatives Facilitate early mobility49,70-75,78 Utilize endotracheal tubes with subglottic secretion drainage ports for patients expected to require greaterthan 48 or 72 hours of mechanical ventilation50 Change the ventilator circuit only if visibly soiled or Elevate the head of the bed to 30⬚–45⬚84-86 Special approaches Good evidence that the intervention Selective oral or digestive decontamination93-96 improves outcomes but insufficientdata available on possible risks May lower VAP rates but insufficient Regular oral care with chlorhexidine98,101-104 data to determine impact on dura- tion of mechanical ventilation, length Ultrathin polyurethane endotracheal tube cuffs120,121 of stay, or mortality Automated control of endotracheal tube cuff Saline instillation before tracheal suctioning124 Mechanical tooth brushing125,126 Lowers VAP rates but ample data sug- Silver-coated endotracheal tubes127 gest no impact on duration of me- chanical ventilation, length of stay, No impact on VAP rates, average dura- Stress ulcer prophylaxis135,136 tion of mechanical ventilation, length Early tracheotomy137 of stay, or mortalityc Monitoring residual gastric volumes138 Early parenteral nutrition139 No recommendation No impact on VAP rates or other pa- Closed/in-line endotracheal suctioning141-143 tient outcomes, unclear impact oncosts a There are very little data on head-of-bed elevation, but it is classified as a basic practice because of its simplicity, ubiquity, low cost, andpotential benefit.
b There are abundant data on the benefits of digestive decontamination but insufficient data on the long-term impact of this strategy onantimicrobial resistance rates.
c May be indicated for reasons other than VAP prevention.
3. Use ultrathin polyurethane endotracheal tube cuffs pressure (quality of evidence: III).
(quality of evidence: III).
a. Automated control of endotracheal tube cuff pres- a. Ultrathin polyurethane cuffs seal more uniformly sure led to lower VAP rates in one trial but not in against the tracheal wall and may therefore allow another.122,123 Neither trial detected an impact on fewer secretions to seep around the cuff and into duration of mechanical ventilation, length of stay, the lungs. Two studies reported lower VAP rates but or mortality.
were underpowered to assess other outcomes.120,121 5. Instill saline before tracheal suctioning (quality of 4. Provide automated control of endotracheal tube cuff evidence: III).
This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM strategies to prevent vap: 2014 update a. One randomized trial in oncology patients found 2. Early tracheotomy (quality of evidence: I).
that saline instillation before tracheal suctioning a. Early versus late tracheotomy had no impact on lowered the rate of microbiologically confirmed VAP rates, duration of mechanical ventilation, or VAP but had no impact on clinical VAP rates or mortality risk on meta-analysis of 7 randomized patient outcomes.124 controlled trials.137 6. Provide mechanical tooth brushing (quality of evi- 3. Monitoring residual gastric volumes (quality of evi- dence: III).
a. One small randomized controlled trial suggested a. Monitoring patients for regurgitation and vomiting that tooth brushing can lower VAP rates, but a meta- alone is as effective as monitoring patients for re- analysis of 4 trials did not detect a significant impact gurgitation, vomiting, and residual gastric volumes on VAP risk, duration of mechanical ventilation, in- with regard to VAP rates, duration of mechanical tensive care length of stay, or mortality.125,126 ventilation, and mortality.138 III. Approaches that are generally not recommended for rou- 4. Early parenteral nutrition (quality of evidence: II).
tine VAP prevention a. Initiation of parenteral nutrition in critically ill pa- A. Generally not recommended for VAP prevention: in- tients within 48 hours of ICU admission is asso- terventions that may lower VAP rates but good-quality ciated with an increased risk of nosocomial infec- evidence suggests no impact on duration of mechanical tions and mortality compared with initiating ventilation, length of stay, or mortality parenteral nutrition on or after 8 days.139 1. Silver-coated endotracheal tubes (quality of evidence: a. A large, multicenter randomized controlled trial A. Interventions with no impact on VAP rates or patient found that silver-coated endotracheal tubes re- outcomes and unclear impact on costs duced VAP rates by 36% but found no impact on 1. Closed endotracheal tube suctioning systems (quality mean duration of mechanical ventilation, hospital of evidence: II).
length of stay, or mortality.127 a. Meta-analyses have found no difference in VAP 2. Kinetic beds (continuous lateral rotational therapy rates, duration of mechanical ventilation, intensive and oscillation therapy; quality of evidence: II).
care length of stay, or mortality between patients a. A meta-analysis of 15 randomized controlled trials randomized to open versus closed endotracheal suc- found a significant decrease in VAP rates but no tioning systems.140-142 A crossover trial in 4 ICUs impact on duration of mechanical ventilation or found no difference between open versus closed sys- mortality.128 The meta-analysis authors warned that tems in patient-to-patient transmissions of gram- the observed reduction in VAP rates might be ar- negative pathogens.143 Different trials have reached tifactual given weaknesses in contributing studies' different conclusions regarding cost.141,144,145 design and execution.
3. Prone positioning (quality of evidence: II).
a. Placing patients in the prone position is contro- Framework for evaluating and prioritizing interventions.
versial. Most meta-analyses suggest a borderline few studies in neonates evaluate the impact of VAP prevention effect on VAP rates and no impact on objective interventions on duration of mechanical ventilation, length outcomes, except among patients with severe acute of stay, or mortality. We therefore evaluated potential inter- respiratory distress syndrome.87,129-134 ventions solely on the basis of safety, feasibility, and potential B. Definitively not recommended for VAP prevention: in- impact on VAP rates. Interventions that lower VAP rates and terventions with good-quality evidence suggesting that confer minimal risks of harm are classified as basic practices.
they neither lower VAP rates nor decrease duration of Interventions with unproven but potential impact on VAP mechanical ventilation, length of stay, or mortality.
rates and minimal risk of harm are classified as special ap- 1. Stress ulcer prophylaxis (quality of evidence: II).
proaches. Hospitals can consider special approaches if their a. Stress ulcer prophylaxis lowers the risk of gastro- VAP rates do not improve despite high performance rates for intestinal bleeding, but meta-analyses suggest that basic practices. Interventions with unknown benefits, known there is no impact on nosocomial pneumonia rates, risks of harm, or unknown risks of harm are not recom- length of stay, or mortality.135,136 Effects may differ in patients receiving enteral nutrition: gastrointes- Specific considerations in preterm neonates.
tinal bleeding is less likely, and stress ulcer pro- used to diagnose VAP in adults have limited utility in preterm phylaxis may increase the risk of nosocomial pneu- neonates. Fever rarely occurs in preterm neonates, since they monia and mortality.135 are prone to hypothermia and are therefore often thermo- b. Stress ulcer prophylaxis may be indicated for rea- regulated with incubators or radiant heaters. Worsening gas sons other than VAP prevention.
exchange or apnea can be caused by significant nonpulmon- This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM infection control and hospital epidemiology august 2014, vol. 35, no. 8 Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Preterm Neonates May lower VAP rates and minimal Use noninvasive positive pressure ventilation in risks of harm; benefits likely out- weigh potential risks Minimize the duration of mechanical ventilation Assess readiness to extubate daily Manage patients without sedation whenever Avoid unplanned extubation152 Provide regular oral care with sterile water Minimize breaks in the ventilator circuit Change the ventilator circuit only if visibly soiled or Special approaches Unknown impact on VAP rates, but Lateral recumbent positioning155 risk of harm likely minimal; reason- Reverse Trendelenburg positioning able to consider implementing if Closed/in-line suctioning systems156,157 rates remain elevated despite basicpractices Unknown impact on VAP rates and in- Regular oral care with antiseptics adequate data on risks May be harmful; risk-benefit balance Histamine 2 receptor antagonists158,159 does not favor intervention unless Prophylactic broad-spectrum antibiotics160-163 specifically indicated for reasons Daily spontaneous breathing trials165,166 other than VAP prevention Daily sedative interruptions Not recommended because appropriate Prophylactic probiotics or synbiotics167,168 products are not available or ap- Endotracheal tubes with subglottic secretion drainage proved for use in this population Silver-coated endotracheal tubes NA, none available.
ary illnesses, including sepsis and necrotizing enterocolitis.
a. Many premature neonates can be successfully sup- New or progressive infiltrates often indicate progression of ported with NIPPV.
chronic lung disease rather than new infection.
B. Minimize the duration of mechanical ventilation Pooled mean VAP rates for neonates reported to the CDC's 1. Manage patients without sedation whenever possible National Healthcare Safety Network (NHSN) vary from 0.2 (quality of evidence: III).150,151 to 1.8 infections per 1,000 ventilator days.146 It is not known 2. Assess readiness to extubate daily (quality of evidence: whether these rates are broadly representative of all neonatal units, however, since many hospitals do not perform VAP 3. Avoid unplanned extubations and reintubations surveillance for neonates in light of the limitations of VAP (quality of evidence: III).152 4. Provide regular oral care with sterile water (extrap- The CDC has not yet developed VAE definitions for neo- olated from studies in adults, no data in preterm nates. Adult VAE definitions are not suitable for neonates, as neonates; quality of evidence: III).
they do not reflect standard ventilator management practices 5. Minimize breaks in the ventilator circuit (extrapo- for this population.
lated from studies in adults, no data in preterm neo- I. Basic practices for preterm neonates: interventions with nates; quality of evidence: III).
minimal risk of harm that may lower VAP rates 6. Change the ventilator circuit only if visibly soiled or A. Avoid intubation if possible malfunctioning (extrapolated from studies in adults 1. Consider nasal continuous positive airway pressure and children, no data in preterm neonates; quality of ventilation with or without nasal intermittent me- evidence: III).153,154 chanical ventilation as an alternative to intubation II. Special approaches for preterm neonates (quality of evidence: I).147-149 A. Interventions with minimal risks of harm but unknown This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM strategies to prevent vap: 2014 update impact on VAP rates as in preterm neonates and adults. The CDC has convened 1. Lateral recumbent positioning (quality of evidence: a working group to consider whether modified VAE defini- tions might be suitable for infants and children.
2. Reverse Trendelenburg positioning (quality of evi- Risk factors for VAP in infants and children are similar to dence: III).
those of adults.172-176 Once they develop teeth, children's oral 3. Closed/in-line flora are similar to those of adults.177,178 In general, most VAP prevention interventions recom- III. Generally not recommended mended for adults are presumed to be applicable to infants A. Inadequate data on risks and unknown impact on VAP and children. Some interventions recommended for adults, rates in preterm neonates however, are not available for infants and small children. For 1. Regular oral care with antiseptic (quality of evidence: example, some specialized endotracheal tubes are available only in larger sizes.
a. There are insufficient data on the impact of altering I. Basic practices for pediatric patients: interventions with neonatal microflora and whether oral antiseptics minimal risk of harm and some data that they lower VAP are absorbed across the oral mucosa of preterm A. Avoid intubation if possible B. May be harmful to preterm neonates 1. Use NIPPV in selected populations whenever feasible 1. Histamine H2-receptor antagonists may increase the (quality of evidence: II).
risk of nosocomial infection and mortality in preterm a. Risks of NIPPV in pediatric patients mirror those neonates (quality of evidence: II).158,159 for adults listed above in section I.A.1.A, with the 2. Prophylactic broad-spectrum antibiotics are associ- added issue that pediatric patients often need se- ated with increased risk of necrotizing enterocolitis, dation to tolerate NIPPV.179,180 prolonged length of stay, and death in premature in-fants (quality of evidence: II).160-163 B. Minimize the duration of mechanical ventilation 3. Spontaneous breathing trials (quality of evidence: 1. Assess readiness to extubate daily in patients without contraindications (quality of evidence: II).181-183 a. Ventilating preterm neonates with prolonged con- a. A randomized controlled trial in Brazil reported tinuous positive airway pressure alone increases the that daily spontaneous breathing trials decreased risk of extubation failure.164-166 the mean duration of ventilation.183 There is no C. Not applicable to preterm neonates consensus on the most effective technique for 1. Daily interruption of sedation (quality of evidence: spontaneous breathing trials in pediatric pa- a. Sedation is not routinely required for neonates on 2. Avoid unplanned extubations and reintubations (quality of evidence: III).185 b. There are no data on the impact of interrupting C. Provide regular oral care sedatives when sedation is used.
1. Provide regular oral care (quality of evidence: III).
2. Prophylactic probiotics and synbiotics (quality of evi- a. Two before-after studies of VAP bundles that dence: III).
emphasized oral care found decreases in VAP a. There are currently no products approved by the US Food and Drug Administration for preterm b. The American Dental Association recommends be- neonates. Limited data suggest that these may ben- ginning oral hygiene a few days after birth.187 Wipe efit some patients, but there are also multiple case the gums with a gauze pad after each feeding to reports of Lactobacillus bacteremia in infants and remove plaque and residual formula that could children following probiotic therapy.167-171 harm erupting teeth. When teeth erupt, brush 3. Endotracheal tubes equipped with subglottic secre- them gently twice a day with a child's size tooth- tion drains; suitably sized products are not commer- brush and water. Fluoride toothpaste is recom- cially available (quality of evidence: none available).
mended from 2 years of age onward. After oral 4. Silver-coated endotracheal tubes; suitably sized prod- hygiene, rinse and suction the mouth. Keep the ucts are not commercially available (quality of evi- oral mucosa and lips clean, moist, and intact using dence: none available).
sponge-tipped applicators dipped in nonalcohol,nonperoxide mouth rinse.186 D. Elevate the head of the bed 1. Elevate the head of the bed unless medically contra- Framework for evaluating and prioritizing interventions.
indicated (quality of evidence: III).
agnosing VAP is as challenging in term infants and children a. One before-after study of a VAP bundle that in- This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM infection control and hospital epidemiology august 2014, vol. 35, no. 8 Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Pediatric Patients Some data that the intervention lowers Use noninvasive positive pressure ventilation for VAP rates and minimal risks of harm; potential benefits likely out- Assess readiness to extubate daily using spontaneous weigh potential risks breathing trials in patients withoutcontraindications182,183 Avoid unplanned extubations185 Provide regular oral care (ie, toothbrushing or gauze if Elevate the head of the bed to 30⬚–45⬚173 Change ventilator circuits only if visibly soiled or Use cuffed endotracheal tubes189,190 Prevent condensate from reaching the patient173,188 Special approaches Unknown impact on VAP rates, but Interrupt sedation daily192 risk of harm likely minimal; reason- Prophylactic probiotics able to consider implementing if Utilize endotracheal tubes with subglottic secretion rates remain elevated despite basic drainage ports for older pediatric patients expected to require greater than 48 or 72 hours of mechanicalventilation50 Unknown impact on VAP rates and in- Systemic antimicrobial therapy for ventilator-associated adequate data on risks Selective oropharyngeal or digestive decontamination No impact on VAP ratesa Oral care with antiseptics, such as chlorhexidine193,195 Stress ulcer prophylaxis199,200 Early tracheotomy Lowers VAP rates in adults, but no im- Silver-coated endotracheal tubes pact on duration of mechanical ven-tilation, length of stay, or mortality No recommendation Limited data on pediatric patients; no impact on VAP rates or outcomes inadults; unclear impact on costs a May, however, be indicated for reasons other than VAP prevention.
cluded head-of-bed elevation observed a decrease quently (quality of evidence: III).
a. Avoid draining the condensate toward the pa- b. Many hospital cribs do not have inbuilt angle-mea- suring devices. Alternative measuring devices are 3. Suction oral secretions before each position change required in these circumstances.
(quality of evidence: III).188 E. Maintain ventilator circuits F. Endotracheal tube selection and maintenance 1. Change ventilator circuits only when visibly soiled or 1. Use cuffed endotracheal tubes (quality of evidence: malfunctioning (quality of evidence: II).
a. One randomized trial and 1 observational study a. Pediatric intensivists have historically favored un- found no difference in VAP rates or mortality with cuffed tubes due to concern that cuffs may induce 3-day versus 7-day circuit changes. Circuit subglottic stenosis in pediatric airways. Cuffing has changes are therefore recommended only when been proven safe, however, and may decrease the the circuit is soiled or malfunctioning, to mini- risk of microaspiration.189,190 Cuffed tubes are now mize costs.153,154 used routinely for term newborns and children.191 2. Remove condensate from the ventilator circuit fre- 2. Maintain cuff pressure and volume at the minimal This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM strategies to prevent vap: 2014 update occlusive settings to prevent clinically significant air 2. Stress ulcer prophylaxis (quality of evidence: III).
leaks around the endotracheal tube, typically 20 cm a. Two small studies found no impact on VAP of water (quality of evidence: III).123,189 a. The potential merits of automated manometers for 3. Early tracheotomy (quality of evidence: III).
VAP prevention have not been studied in pediatric 4. Thromboembolism prophylaxis (quality of evidence: II. Special approaches for pediatric patients C. Lowers VAP rates but no impact on duration of me- A. Interventions with evidence of benefit in adult pa- chanical ventilation, length of stay, or mortality tients and minimal risks of harm but limited data in pe- 1. Silver-coated endotracheal tubes (quality of evidence: diatric populations 1. Interrupt sedation once a day (quality of evidence: IV. No recommendation: limited data from pediatric studies, no impact on VAP rates or outcomes in adults, unclear a. Daily sedative interruptions decreased duration of mechanical ventilation and intensive care length of A. Closed/in-line suctioning stay without increases in adverse event rates in 1 1. An observational study of open versus closed suc- small randomized controlled trial.192 tioning in children did not find any difference in VAP b. There is nonetheless concern that sedative inter- rates, length of stay, or mortality, but the significance ruptions will increase the frequency of unplanned of these findings are unclear given the lack of blinding extubations and reintubations in younger patients, and randomization (quality of evidence: III).201 so this practice may be safest in older pediatricpatients. More data are needed.
2. Administer prophylactic probiotics (quality of evi- dence: III).
I. Internal reporting a. This recommendation is inferred from adult data A. Regular monitoring and internal reporting of patient but should be considered with caution due to outcomes and adherence rates to recommended pre- sparse safety data in pediatric patients and case vention strategies ("process measures") are important reports of Lactobacillus bacteremia associated with quality improvement strategies.
probiotic therapy, including cases in children with- B. Both outcome and process measure reporting are likely out known immunodeficiency.111-114,169-171 beneficial: improving outcomes is the primary goal of 3. Use endotracheal tubes with subglottic secretion care improvement programs, but analyzing perfor- drainage ports (quality of evidence: III).
mance rates for key processes of care may help identify a. This intervention is feasible only for children aged specific processes to target for improvement.
greater than or equal to 10 years since the smallest C. Report process and outcome measures to key organi- available endotracheal tube with subglottic secre- zational stakeholders, including frontline care provid- tion drainage ports is size 6.0.
ers, respiratory therapy directors, nursing and medical III. Generally not recommended for pediatric patients leaders, and senior hospital administrators. Feeding A. Unknown impact on VAP rates and/or inadequate data these data back to providers and leaders has been as- sociated with improvements in both performance rates 1. Systemic antimicrobial therapy for ventilator-asso- and outcomes.202-207 ciated tracheobronchitis (quality of evidence: III).
D. Report process measures internally only. External re- a. One retrospective study found that prolonged an- porting of process measure data is not appropriate at tibiotics for tracheobronchitis did not protect this time given substantial variability in the ways dif- against VAP but did increase the prevalence of mul- ferent organizations define, collect, analyze, and present process measure data.
2. Selective oropharyngeal or digestive decontamination E. There are insufficient data at present to guide the def- (quality of evidence: III).
inition and implementation of process measures for the a. See comments in section on adults.
prevention of VAP in neonatal and pediatric units.
B. No impact on VAP rates (these interventions may, how- II. Process measures ever, be indicated for reasons other than VAP A. Process measure definitions and measurement strate- 1. Oral care with chlorhexidine (quality of evidence: II).
1. For organizations that collect and report process mea- a. Chlorhexidine appears to be safe for developing sures, clearly define measures, including data sources, teeth,194 but randomized controlled trials have inclusion and exclusion criteria, frequency of mon- found no difference in VAP rates, length of stay, itoring, and numerator and denominator criteria.
or mortality in infants and children.193,195-198 2. Develop a formal system to document compliance.
This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM infection control and hospital epidemiology august 2014, vol. 35, no. 8 a. Compliance can be measured via direct observa- (a) Girard et al48 defined this as the percentage tions or via audits of patient charts, bedside pa- of sedative-days (ventilator-days during perwork, and/or electronic medical records. Peri- which sedatives are administered) on which odically validate the accuracy of paper and/or sedative and analgesic continuous infusions were interrupted or where at least 1 sched- 3. Perform assessments regularly.
uled dose of an intermittently prescribed a. The optimal frequency of assessments (eg, once sedative or analgesic was withheld.
daily, twice daily, or weekly) is not known, but the (b) Berenholtz et al207 defined this as the per- frequency can likely be adjusted on the basis of centage of ventilator-days on which patients compliance rates (eg, as compliance improves, less prescribed any sedative medications were frequent observations may be sufficient).
able to follow commands at least once dur- B. Prevention bundles ing the course of the day.
1. Consider combining a core set of critical process mea- b. Inclusion criteria: all patients on mechanical sures together into a bundle to enhance care. Bundling ventilation being treated with 1 or more of the care processes facilitates implementation by providing following drugs: lorazepam, midazolam, pro- a clear, tangible set of expectations to follow. In ad- pofol, fentanyl, morphine, meperidine, hydro- dition, some care processes may be synergistic.
morphone, or dexmedetomidine.207 2. There is no consensus on which care processes to c. Exclusion criteria: patients receiving a sedative include in a VAP prevention bundle. There is sub- infusion for active seizures or alcohol with- stantial heterogeneity in different hospitals' ventilator drawal, escalating sedative doses due to ongoing agitation, neuromuscular blockade, evidence of 3. Evidence on the impact of bundles is limited. Many active myocardial ischemia within the previous prevention bundles have been associated with variable 24 hours, evidence of increased intracranial reductions in VAP rates. A smaller subset has been associated with improvements in objective out- 3. Expedite extubation comes.209-214 To date, however, prevention bundles A. Perform spontaneous breathing trials daily have been tested only in observational before-after and time-series analyses rather than in randomized i. Percentage of ventilator-days on which pa- controlled trials. It is therefore difficult to disentangle tients received a trial of spontaneous venti- the extent to which lower VAP rates and better out- lation. A trial of spontaneous breathing is de- comes are due to prevention bundles versus secular fined as a period of time where ventilatory trends in severity of illness, advances in medical care, support is removed. This can be done by al- and ascertainment biases.
lowing the patient to 4. Compliance can be reported for each process measure (a) Breathe through a T-tube circuit individually and/or as all-or-none compliance with a (b) Breathe through a ventilator circuit using bundle of process measures. For all-or-none com- "flow triggering" with continuous positive pliance, credit is given only if all components have airway pressure of 0–5 cm of water and/ been accomplished and documented; if any com- or pressure support ventilation with 5–8 ponents were not performed and/or were not doc- cm of water.48,207,217 umented, no credit is given.212,215 ii. The initial spontaneous breathing trial should III. Approaches to defining process measures last at least 30 minutes.
A. There is no consensus on how best to define adherence b. Inclusion criteria: all patients on mechanical to different process measures. Examples of how differ- ent organizations have defined selected process mea- c. Exclusion criteria: oxygen saturation less than sures are summarized below. These examples are pri- 88%, Fio greater than 50%, PEEP greater than marily drawn from multicenter quality improvement 8 cm of water, lack of spontaneous breathing effort for greater than or equal to 5 minutes, 1. Optimize hand hygiene agitation, active myocardial ischemia, significant a. Readers are referred to the Compendium article vasopressor requirement, increased intracranial "Strategies to Prevent Healthcare-Associated Infec- pressure, moribund state with death likely tions through Hand Hygiene"216 for a comprehen- sive discussion of this topic.
4. Minimize the risk of aspiration 2. Minimize sedation a. Elevate the head of the bed a. Perform spontaneous awakening trials daily.
i. Definitions i. Definitions (a) Berenholtz et al207 defined this as the per- This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM strategies to prevent vap: 2014 update centage of ventilator-days on which the head iii. Multiply by 1,000 and express as the overall of the bed is elevated 30⬚–45⬚.
VAP rate per 1,000 ventilator-days.
(b) Bloos et al213 had access to continuous elec- c. Probable VAP rate tronic monitoring of their beds' backrest el- i. Numerator: total number of all probable VAP evation angles. They therefore defined head- of-bed elevation compliance as the mean ii. Denominator: total ventilator-days.
daily backrest elevation angle.
iii. Multiply by 1,000 and express as the probable (c) Sinuff et al214 tracked concordance with VAP rate per 1,000 ventilator-days.
head-of-bed elevation to 45⬚. They defined V. External reporting concordance as the sum of days on which A. VAC and IVAC are potentially appropriate metrics for the head of the bed was elevated plus the public reporting, interfacility comparison, and pay-for- days on which head-of-bed elevation was performance programs. Better data on their respon- contraindicated divided by total ventilator- siveness to quality improvement programs are neces- days. They encouraged providers to consider elevating the head of the bed as much as interfacility comparisons or pay-for-performance pro- possible when elevation to 45⬚ was not grams. Suitable risk-adjustment strategies are also ii. Inclusion criteria: all patients on mechanical B. Possible and probable VAP are not suitable for external reporting at this time since substantial variability in iii. Exclusion criteria: patients with hemodynamic clinical and laboratory practices in the acquisition, pro- instability, undergoing resuscitation, unstable cessing, and interpretation of culture data preclude spine or not cleared, pelvic instability or frac- tures, prone position, intra-aortic balloon pump in femoral vessels, and obesity procedures.214 C. VAP rates generated using NHSN's former surveillance IV. Outcome measures definitions are not appropriate for external reporting A. Conduct surveillance for all VAEs, including VAC, in light of their considerable subjectivity.
IVAC, possible VAP, and probable VAP in adult ICUs.
D. Hospitals in states that have mandatory reporting laws Report rates for all events included in the algorithm.
must collect and report data as required by their state.
VAE definitions are not currently available for pediatric Local and state health departments can provide specific and neonatal patients; hence, these units should con- information on public reporting requirements.
tinue to use traditional NHSN VAP definitions.
1. VAE incidence density a. Numerator: total number of VACs, including IVACs, possible VAPs, and probable VAPs.
b. Denominator: total ventilator-days.
Accountability is an essential principle for preventing HAIs.
c. Multiply by 1,000 and express as VAEs per 1,000 It provides the necessary translational link between science and implementation. Without clear accountability, scientifi- d. Note that the total VAE rate is synonymous with cally based implementation strategies will be used in an in- the total VAC rate.
consistent and fragmented way, decreasing their effectiveness 2. IVAC incidence density in preventing HAIs. Accountability begins with the chief ex- a. Numerator: total number of IVACs, including pos- ecutive officer and other senior leaders who provide the im- sible VAPs and probable VAPs.
perative for HAI prevention, thereby making HAI prevention b. Denominator: total ventilator-days.
an organizational priority. Senior leadership is accountable c. Multiply by 1,000 and express as the IVAC rate per for providing adequate resources needed for effective imple- mentation of an HAI prevention program. These resources 3. VAP incidence density include necessary personnel (clinical and nonclinical), edu- a. Organizations can consider calculating both their cation, and equipment (Table 5).
total VAP rate (sum of possible and probable VAPs) Engagement, education, execution, and evaluation are fur- and their probable VAP rate for internal monitor- ther common attributes of successful care improvement pro- ing purposes. The former metric is presumed to grams.203 These attributes are elaborated below.
be more sensitive, the latter more specific.
b. Total VAP rate i. Numerator: total number of all possible and A. Develop a multidisciplinary team probable VAPs.
1. Multidisciplinary teams set goals, define each step in ii. Denominator: total ventilator-days.
the implementation process, and monitor progress in This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM infection control and hospital epidemiology august 2014, vol. 35, no. 8 Fundamental Elements of Accountability for Healthcare-Associated Infection Prevention Senior management is responsible for ensuring that the healthcare system supports an infection prevention and control (IPC) pro- gram that effectively prevents healthcare-associated infections (HAIs) and the transmission of epidemiologically importantpathogens Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the IPC program and adequate staffing of other departments that play a key role in HAI prevention (eg, environmental services) Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are ade- quately trained and competent to perform their job responsibilities Direct healthcare providers (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as environmental service and equipment processing personnel) are responsible for ensuring that appropriate IPC practices are used at all times (includinghand hygiene, standard and isolation precautions, and cleaning and disinfection of equipment and the environment) Senior and unit leaders are responsible for holding personnel accountable for their actionsIPC leadership is responsible for ensuring that an active program to identify HAIs is implemented, that HAI data are analyzed and regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospitaladministrators), and that evidence-based practices are incorporated into the program Senior and unit leaders are accountable for ensuring that appropriate training and educational programs to prevent HAIs are devel- oped and provided to personnel, patients, and families Personnel from the IPC program, the laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program reaching goals.173,218,219 Programs developed by team learn from best practices, brainstorm solutions to com- consensus are more effective and increase guideline mon problems, and promulgate local successes.227 adherence.173,218,220 Multidisciplinary teams include representatives from all disciplines that care for ven- A. Provide education sessions tilated patients, including, at a minimum, unit di- 1. Education sessions help summarize evidence, explain rectors, physicians, nurses, and respiratory therapists.
new processes, set expectations, and encourage staff Other partners who can strengthen the team include to adopt recommended practices.202,228 Education ses- infection preventionists, pharmacists, nutritionists, sions can include workshops, hands-on trainings, physical therapists, occupational therapists, family conferences, slide presentations, and/or interactive members, and patient advocates.207,219,221,222 discussions; employing multiple teaching modalities B. Involve local champions can help meet diverse learning styles.224,229,230 Both lo- 1. Identify local champions, including formal (eg, med- cal champions and topic experts (eg, infection pre- ical director, nursing director, charge nurses, director ventionists) can lead staff education.173,226 of respiratory therapy) and informal (eg, engaged 2. Education sessions must be informative and relevant frontline staff) leaders.207,213,219,221-223 for the learner; therefore, it is important to have mul- 2. Local champions are important to success because they tidisciplinary educational programs customized for engage stakeholders, educate peers, encourage ongoing improvement, and increase buy-in and ownership by 3. Ongoing staff education helps maintain high levels both staff and administrators.173,203,207,220,223,224 of compliance with recommended practices.205,230 3. Local champions should know their hospital's inter- 4. Educating patients and family members may help ests and needs, be able to shape strategies to match them better engage with and support the medical local unit culture, monitor progress, and facilitate team's plan of care.
necessary changes during implementation.202 Early B. Provide educational materials and continual communication between local cham- 1. Provide educational materials to staff that summarize pions and frontline staff allows providers to ask ques- the evidence, support self-study, and remind staff tions, resolve concerns, prepare for action, and sus- about new practices.231 Examples of educational ma- terials include pocket cards, brochures, posters, fact C. Utilize peer networks sheets, daily guides, guideline summaries, flow sheets 1. Horizontal networking of peers across hospitals can and 1-page bulletins.173,205,207,227,229,232 promote and increase compliance with evidence-based best practices. Voluntary peer networks encourage col- A. Standardize care processes laboration, analysis of performance, accountability, 1. Standardize care processes through the implemen- and commitment to specific goals.207,225-227 Comparing tation of guidelines, bundles, protocols, or pathways.
progress and benchmarks between ICUs can help units Standardization helps establish new care processes as better understand their local strengths and weaknesses, "normal behaviors" for staff.202 This content downloaded from on Mon, 21 Jul 2014 17:07:44 PM

strategies to prevent vap: 2014 update 2. Daily multidisciplinary rounds are widely advocated; these rounds should follow a structured format and S.S.M.—The findings and conclusions in this report are those include discussion about the patients' goals for the of the authors and do not necessarily represent the official position of the day, consideration of what resources and actions are Centers for Disease Control and Prevention.
Potential conflicts of interest. M.K. reports having received honoraria for necessary to achieve these goals, and identification of lectures from Premier Healthcare Alliance. L.R.G. reports having received potential barriers and/or safety issues.204,207,222 honoraria from Premier, Care Fusion, Infection Control Today, and Advanced B. Create redundancy Sterilization Products. R.B. reports having served as an advisor/consultant 1. Build redundancy or independent checks into care- for Covidien, Hamilton, Advanced Circulatory Systems, and Ikaria. E.C.E.,M.D.H., G.L., L.L.M., S.S.M., G.P.P., K.S., D.S.Y., and S.M.B. report no con- delivery processes to remind staff about new prac- flicts of interest.
tices.202,203,212 Redundancy can take the form of posters,bulletins, pens, stamps, pocket cards, 1-page signs, Address correspondence to Michael Klompas, MD, MPH, Department daily goals in patient rooms, checklists and preprinted of Population Medicine, Harvard Medical School and Harvard Pilgrim order sets, text messages, and screen savers on clinical Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215 computers.203,205,212,226,232-235 Encourage family members to ask the care team if patients are receiving evidence-based therapies for VAP prevention.207 2. The combination of both education and reminders significantly improves processes of care.228,236 1. 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–S40.
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CliniCal Guidelines Diagnosis and Treatment of Polycystic Ovary Syndrome: An Endocrine Society Clinical Practice Guideline Authors: Richard s. legro, silva a. arslanian, david a. ehrmann, Kathleen M. Hoeger, M. Hassan Murad, Renato Pasquali, and Corrine K. Welt Affiliations: The Penn state university College of Medicine (R.s.l.), Hershey, Pennsylvania 17033; Children's Hospital of Pittsburgh (s.a.a.), university of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15224; university of Chicago (d.a.e.), Chicago, illinois 60637; university of Rochester Medical Center (K.M.H.), Rochester, new York 14627; Mayo Clinic (M.H.M.), Rochester, Minnesota 55905; Orsola-Malpighi Hospital, university alma Mater studiorum, (R.P.), 40126 Bologna, italy; and Massachusetts General Hospital (C.K.W.), Boston, Massachusetts 02114

The antimalarial and people suffering from the disease per year. Africa accounts forover 90% of reported cases, with an annual 20% increase of cytotoxic drug cryptolepine malaria-related illness and death. Malaria is responsible for as many deaths per annum as AIDS for all of the last 15 years. Drug intercalates into DNA at resistance to malaria has become one of the most significantthreats to human health and the search for new effective drugs is