Furthermore, the recent outbreak of vancomycin-resistant or glycopeptide-resis-tant S aureus infections in a French ICU was difficult to control, and costly, and may be a harbinger of future problems, especially with the recent reduction in vancomycin sensitivity from a minimum inhibition concentration of 4 to 2 ^g/mL. Control of MRSA will require more aggressive antibiotic control, focused on reduced use of antibiotics, such as fluoroquinolones and improved infection control. Infection control for high-risk populations and certain health-care facilities may require improved screening, isolation, and eradication of MRSA, such as the “search and destroy” strategy recently outlined by Vos and coworkers.
Bacterial colonization of the aerodigestive tract and entry of contaminated secretions into the lower respiratory tract are critical in the pathogenesis of VAP and major targets for prevention (Fig 1). The endotracheal tube is a major risk factor for VAP, as it permits leakage of oropharyngeal secretions around the cuff and may act as a nidus for the growth of intraluminal biofilm. other
Suggested Basic Prevention Strategies Multidisciplinary Team Approach to Prevention
Prevention efforts targeting VAP must be part of an evidence-based, multidisciplinary prevention program that has a “core” team with an agenda focused on patient safety and quality improvement (Fig 2, 3). Optimally, the team should be led by a “champion” of the cause and include interested clinicians, respiratory care staff, administrators, risk management staff, and other stakeholders as core team members (Fig 3). The responsibilities of this group include setting prevention benchmarks, establishing goals and time lines, and providing appropriate education and training, audits, and feedback to the staff, while continually updating themselves on the relevant clinical and prevention strategies.
Prevention programs should be “marketed” to hospital administrators and others involved in resource allocation by demonstrating that preventing VAP results in improved clinical outcomes and significantly reduced costs. Data from Rello in 2002, demonstrated that on average, a case of VAP increased hospitalization by 12 days, mechanical ventilation by 10 days, ICU stay by 6 days, and hospital costs by $40,000; similar results have been reported in a suburban hospital by Warren and coworkers.- In addition to these direct savings, the growing trend of public reporting of institution-specific infection rates and other outcome data are not only increasing but may eventually effect hospital reimbursement rates.
Figure 1. VAP pathogenesis: risk factors for colonization, entry into the lower airway, and interactions between the invaders and host defenses that will decide between colonization of VAP.
Figure 2. Multidisciplinary prevention team is recommended to implement evidence-based guidelines for VAP prevention into routine clinical practice.
Figure 3. Summary of the agenda for VAP prevention.