Prevention of ventilator associated pneumonia

Objectives; To assess the clinical and cost effectiveness of prophylactic antibiotics, body position, kinetic bed therapy and care bundles for the prevention of ventilator associated pneumonia. Data sources; Searches of main electronic databases were conducted in April and June 2007. Review methods; Systematic reviews and randomised controlled trials were included if they had the interventions of interest as one of the treatment arms and the population were intensive care unit patients requiring mechanical ventilation for 48 hours or more. Results; Prophylactic antibiotics, There are concerns that use of topical antibiotics in selective decontamination of the digestive tract may lead to microbial resistance. Furthermore, incidence of clostridium difficile colitis and central line infections are reported to increase in those who received prolonged prophylactic antibiotics. Ampicillin-sulbactam, orabase with gentamicin, colistin, and vancomycin, and gentamicin, polymyxin E and amphotericin B all showed a statistical significant reduction in the incidence of VAP. Body position None of the RCTs on body positioning appeared to be robust well conducted studies, There are concerns regarding that when patients are positioned between 30 and 45 patients have slid down in bed and, if skin integrity is compromised, the shearing of skin occurs. Of the three RCTs, only one reported a statistically significant reduction in the incidence of VAP, using a semi recumbent body position of 45 degrees. Kinetic bed therapy Two systematic reviews of kinetic bed therapy for the prevention of VAP in ICU patients were identified, only one was judged to be a robust systematic review. It was noted that poor methodological quality clinical trials were included in the meta-analysis. Both reviews carried out a meta-analysis and both studies found that kinetic bed therapy is associated with a significant reduction in the odds of developing nosocomial pneumonia in mechanically ventilated patients. Care bundles Only two studies that recorded VAP rates before and after the introduction of a ventilator bundle were identified Both of these studies used the IHI care bundle as a basis, but added other components to it both reported a reduction in VAP rates after the introduction of a ventilator bundle. The results of the cost-effectiveness analysis of interventions aimed at preventing VAP in ICU patients undergoing MV shows that there are three main interventions that have the highest probabilities of being the most cost-effective options. These are an SDD alone antibiotic regimen, a SDD + non-SDD antibiotic regimen, and the more extensive care bundle. Conclusions; Prophylactic antibiotics, There is no evidence to support the routine use of ceftazidime for prophylaxis, but ampicillin-sulbactam, orabase with gentamicin, colistin, and vancomycin, and gentamicin, polymyxin E and amphotericin B did all show a statistical significant reduction in the incidence of VAP, but further research on the complications caused by antibiotic use is needed before firm recommendations can be made. Body position, semi recumbent patient position is a low-cost and practical intervention but, a backrest elevation of 45 degrees is not always achieved.