VAP Prevention in the ICU

Critically ill patients admitted to an intensive care unit for a life-threatening condition (both medical and surgical) can contract a ventilator-associated pneumonia (VAP). This is an infection acquired by virtue of being on mechanical ventilation in a host who has lost the normal integrity of their respiratory tract defense mechanisms, and often times also has a deficient innate immunity secondary to their critical illness. Several risk factors have been reported to be associated with developing a VAP. This would include duration of mechanical ventilation, sepsis, trauma, neurological disease, chronic pulmonary disease, acute respiratory distress syndrome (ARDS), prior use of antibiotics, and red cell transfusions (Tejerina et al., J Crit Care 21:56–65, 2006). This nosocomial infection increases morbidity, mortality, as well as the cost of health care (due to longer ICU and hospital length of stay). Mortality rates in patients with VAP range from 20% to 50% and may reach more than 70% when the infection is caused by multiresistant and invasive pathogens (Heyland et al., Am J Respir Crit Care Med 159:1249–1256, 1999). Unfortunately, there is no consensus on the diagnosis of a VAP but in general the presence of fever, leukocytosis (or leukopenia), new or worsening infiltrates of chest radiography, purulent tracheobronchial secretions, and culture would contribute to a diagnosis, often times on a point system (Grgurich et al., Curr Opin Infect Dis 26(2):140–150, 2013). The bacteria most often implicated are typically more virulent and are more likely to be drug resistant. Delayed diagnosis and subsequent delay in initiating appropriate therapy can be associated with worse outcomes in patients with VAP (Iregui et al., Chest 122:262–268, 2002). This article reviews the literature with regard to VAP prevention strategies.