NEW YORK (Reuters Health) – A multifaceted program aimed at increasing compliance with preventive measures leads to a sustained reduction in the rate of ventilator-associated pneumonia (VAP), a French team has shown.

However, they also found that the rates are still substantial, and suggest that “eliminating VAP in the intensive care unit may be an unrealistic goal,” according to the report in the November 15th issue of Clinical Infectious Diseases.

Dr. Jean-Christophe Lucet at Hopital Bichat-Claude-Bernard in Paris and colleagues note that many studies have shown VAP rates can be decreased with single measures, and lately bundled preventive measures have been tried.

In their case, the team developed a program for VAP prevention in the ICU at Bichat-Claude-Bernard Hospital focusing on eight measures. “The multifaceted program significantly improved compliance with the 8 targeted measures,” the team reports.

“Compliance with hand hygiene and glove-and-gown use rules was high at baseline (68% and 80%, respectively) and remained stable over time,” they continue. “Compliance with the following preventive measures was low at baseline and increased steadily over time: keeping patients in the semirecumbent position (5%–58%), maintaining an endotracheal tube cuff pressure 120 cm H2O (40%–89%), using an orogastric tube rather than a nasogastric tube (52%–96%), avoiding gastric overdistension (20%–68%), decontaminating the patient’s mouth with 0.12% chlorhexidine at least 4 times per day (47%–90%), and no use of nonessential tracheal suction (41%–92%).”

For the present study, Dr. Lucet’s team compared VAP rates in the 45 months before the intervention with a 30-month period after the program was launched.

Among patents who received ventilation for at least 48 hours, 23.2% had at least one VAP episode in the baseline period compared to 14.1% in the intervention period (p<0.001), according to the report. The pattern was similar when VAP occurrence was measured as the incidence density rate, expressed as the total number of VAP episodes per 1000 ventilation days: 22.6 during the baseline period and 13.1 during the intervention period (p<0.001). The length of ICU stay was significantly shorter after the intervention. However, there was no significant differences between the two periods in duration of mechanical ventilation or in the death rate. “In conclusion,” Dr. Lucet and colleagues write, “our program for preventing VAP in the ICU was successful, with sustained improvements during 3 years. However, the VAP rates remained substantial despite high compliance with most of the preventive measures, suggesting that some VAP episodes may not be preventable in the ICU setting.” In an accompanying editorial, Dr. Michael Klompas of Harvard Medical School and Harvard Pilgrim Health Care Institute in Boston, Massachusetts, takes issue with two aspects of the study: limitations in its design and limitations to the surveillance definition of VAP. “Ultimately,” he writes, “the striking disparity in the impact of this bundle on VAP rates versus patient outcomes is urgent impetus to develop a more objective surveillance definition for complications of mechanical ventilation rather than proof that VAP cannot be eliminated.” Reference:
Long‐Term Impact of a Multifaceted Prevention Program on Ventilator‐Associated Pneumonia in a Medical Intensive Care Unit

Clin Infect Dis 2010.