Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia.

BACKGROUND Ventilator-associated pneumonia (VAP) is an important patient safety issue in critically ill patients. PURPOSE To develop an evidence-based guideline for the prevention of VAP. DATA SOURCES MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews. STUDY SELECTION The authors systematically searched for relevant randomized, controlled trials and systematic reviews that involved mechanically ventilated adults and were published before 1 April 2003. DATA EXTRACTION Physical, positional, and pharmacologic interventions that may influence the development of VAP were considered. Independently and in duplicate, the authors scored the validity of trials; the effect size and confidence intervals; the homogeneity of results; and safety, feasibility, and economic issues. DATA SYNTHESIS Recommended: The orotracheal route of intubation, changes of ventilator circuits only for each new patient and if the circuits are soiled, use of closed endotracheal suction systems that are changed for each new patient and as clinically indicated, heat and moisture exchangers in the absence of contraindications, weekly changes of heat and moisture exchangers, and semi-recumbent positioning in the absence of contraindications. Consider subglottic secretion drainage and kinetic beds. Not recommended: Sucralfate to prevent VAP in patients at high risk for gastrointestinal bleeding and topical antibiotics to prevent VAP. Because of insufficient or conflicting evidence, no recommendations were made about systematically searching for maxillary sinusitis, chest physiotherapy, the timing of tracheostomy, prone positioning, prophylactic intravenous antibiotics, or intravenous plus topical antibiotics. LIMITATIONS No formal economic analysis was performed, and patient perspectives were not considered. CONCLUSION If effectively implemented, this guideline may decrease the morbidity, mortality, and costs of VAP in mechanically ventilated patients.