American Journal of Infection Control 42 (2014) 935-40
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Letters to the Editor
Ventilator-associated pneumonia: Survey of infection control practices in intensive care units of 15 tertiary care hospitals in Mumbai To the Editor: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in patients hospitalized in intensive care units (ICUs). Meticulous implementation of infection control measures is a key component for reducing the incidence of VAP. The Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Association for the Profession of Infection Control and Epidemiology, and Centers for Disease Control and Prevention provide guidelines1-3 that comprehensively review the infection control measures for VAP prevention and provide evidence-based recommendations. Studies have shown that the efficient implementation of VAP care bundles decreases the incidence of VAP4,5 and significantly improves outcomes. But although clear recommendations are now available for many components of these bundles (eg, semirecumbent patient positioning), there remain controversies over certain issues (eg, selective digestive tract decontamination). We conducted a survey to determine the VAP policies and practices in various Mumbai hospital ICUs and to compare them for uniformity and differences. A prestructured questionnaire designed to cover the important VAP prevention practices and procedures were circulated to participating hospitals in Mumbai. Respondents included 15 multispecialty tertiary care hospitals. The results of the survey are shown in Figure 1. Other relevant findings included the following. Closed suction systems were used by two-thirds of the respondents; 53.3% reported changing the suction system when it was soiled, 26.67% reported changing the system every 48 hours, and 13.3% reported changing the system every 24 hours. Sixty percent of respondents reported changing the ventilator circuit when it was soiled, 20% reported changing it at 48 hours, and 13.3% reported changing it at 7 days. Heat moisture exchanger humidifiers were used by all respondents; approximately 20% of respondents changed the humidifier at 24 hours, 53.33% did so at 48 hours and 13.33% did so after 72 hours. The important components of ventilator patient care aimed at reducing infection include preventing inspiration of oropharyngeal secretions, preventing contamination of equipment, preventing
colonization of the aerodigestive tract, implementating the VAP care bundle, maintaining meticulous practice, and consistently reinforcing general infection control practices.6 The points covered in this survey were intended to address the aforementioned aspects, which play major roles in reducing the incidence of VAP. One major discrepancy in practice noted in our survey was related to suctioning practices. The effect of closed suction systems on the incidence of VAP remains a matter of debate, with studies reporting inconsistent results. Reductions in colonization may be better achieved by the use of closed suction systems, which also permit continuous ventilation and is safer in view of the much lower risk of aerosolization and is recommended by the American Association for Respiratory Care.7 Another important step in preventing aspiration in ventilated patients is removing subglottic secretions that may accumulate above the endotracheal tube cuff. In patients expected to be ventilated for more than 72 hours, the use of a specialized endotracheal tube with an inbuilt system for subglottic suction to remove oropharyngeal secretions was effective in reducing earlyonset VAP, as demonstrated in a meta-analysis,8 and thus is recommended. The use of kinetic (ie, continuous lateral rotation) beds, although shown to be effective9 in reducing VAP, is limited by safety and cost concerns, as evidenced by its use in
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Letters to the Editor
Ventilator-associated pneumonia: Survey of infection control practices in intensive care units of 15 tertiary care hospitals in Mumbai To the Editor: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in patients hospitalized in intensive care units (ICUs). Meticulous implementation of infection control measures is a key component for reducing the incidence of VAP. The Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Association for the Profession of Infection Control and Epidemiology, and Centers for Disease Control and Prevention provide guidelines1-3 that comprehensively review the infection control measures for VAP prevention and provide evidence-based recommendations. Studies have shown that the efficient implementation of VAP care bundles decreases the incidence of VAP4,5 and significantly improves outcomes. But although clear recommendations are now available for many components of these bundles (eg, semirecumbent patient positioning), there remain controversies over certain issues (eg, selective digestive tract decontamination). We conducted a survey to determine the VAP policies and practices in various Mumbai hospital ICUs and to compare them for uniformity and differences. A prestructured questionnaire designed to cover the important VAP prevention practices and procedures were circulated to participating hospitals in Mumbai. Respondents included 15 multispecialty tertiary care hospitals. The results of the survey are shown in Figure 1. Other relevant findings included the following. Closed suction systems were used by two-thirds of the respondents; 53.3% reported changing the suction system when it was soiled, 26.67% reported changing the system every 48 hours, and 13.3% reported changing the system every 24 hours. Sixty percent of respondents reported changing the ventilator circuit when it was soiled, 20% reported changing it at 48 hours, and 13.3% reported changing it at 7 days. Heat moisture exchanger humidifiers were used by all respondents; approximately 20% of respondents changed the humidifier at 24 hours, 53.33% did so at 48 hours and 13.33% did so after 72 hours. The important components of ventilator patient care aimed at reducing infection include preventing inspiration of oropharyngeal secretions, preventing contamination of equipment, preventing
colonization of the aerodigestive tract, implementating the VAP care bundle, maintaining meticulous practice, and consistently reinforcing general infection control practices.6 The points covered in this survey were intended to address the aforementioned aspects, which play major roles in reducing the incidence of VAP. One major discrepancy in practice noted in our survey was related to suctioning practices. The effect of closed suction systems on the incidence of VAP remains a matter of debate, with studies reporting inconsistent results. Reductions in colonization may be better achieved by the use of closed suction systems, which also permit continuous ventilation and is safer in view of the much lower risk of aerosolization and is recommended by the American Association for Respiratory Care.7 Another important step in preventing aspiration in ventilated patients is removing subglottic secretions that may accumulate above the endotracheal tube cuff. In patients expected to be ventilated for more than 72 hours, the use of a specialized endotracheal tube with an inbuilt system for subglottic suction to remove oropharyngeal secretions was effective in reducing earlyonset VAP, as demonstrated in a meta-analysis,8 and thus is recommended. The use of kinetic (ie, continuous lateral rotation) beds, although shown to be effective9 in reducing VAP, is limited by safety and cost concerns, as evidenced by its use in
