Medicine of the Future in America

Preventing Ventilator-Associated Pneumonia in Adults: Transfusion Risk

Preventing Ventilator-Associated Pneumonia in Adults: Transfusion RiskAlthough transfusion was suggested as a risk factor of nosocomial infection and a modifiable risk factor for VAP in the American Thoracic Society/Infectious Diseases Society of America guideline, in a secondary analysis from a recent, large study of transfusions, it was identified as an independent risk factor for VAP. This may become a more important modifiable risk factor, as recent data from Levy and coworkers reported that patients receiving mechanical ventilation received transfusions at a higher pretransfusion hemoglobin level than patients not receiving mechanical ventilation (8.7 vs 8.2, p < 0.0001).
Oral care has been recommended to prevent VAP in several studies. In a recent study, Mori and coworkers compared rates of VAP in a nonrandomized group compared with historical control subjects. Incidence of VAP in the oral care group was 3.9 episodes/1,000 days vs 10.4 episodes in the control group. Although there are concerns about the study design, oral care has intuitive benefits and limited cost. Reading here
The GI tract, VAP, and the clinical evidence for the efficacy of selective decontamination of the digestive tract (SDD) were recently review by Kallet and Quinn. Furthermore, Liberati and coworkers published an extensive review of antibiotic prophylaxis to reduce respiratory tract infections in adults receiving intensive care. The authors conclude that for topical and systemic antibiotic prophylaxis, 5 patients would need to be treated to prevent one infection and 21 patients would need to be treated to prevent one death. No recommendation was made for topical prophylaxis. In a recent large study of SDD by de Jonge and coworkers in 2003, SDD was highly effective with no increased antibiotic resistance observed. Citing concerns over rapid increases in antimicrobial resistance in the hospital setting, coupled with the association between MDR pathogens and poorer patients outcomes and the dearth of new antimicrobial agents in the pipeline, recent guidelines have suggested that SDD should considered for selected ICU populations and clinical scenarios but not be employed “routinely” for VAP prevention. Topical antiseptics, such as chlorhexidine, provide an attractive alternative, but the initial reported success in cardiac surgery patients could not be confirmed by other studies. Koeman and cowork-ers provide further important data from a multicenter, double-blind, randomized, clinical trial of VAP outcomes for subjects treated with 2% chlo-rhexidine paste vs patients randomized to 2% chlo-rhexidine plus 2% colistin paste to provide greater activity against Gram-negative bacilli compared to placebo. Compared to the placebo group, the daily risk of VAP was reduced by 65% in the chlorhexidine group (p =.01) and 55% in the chlorhexidine-colis-tin group (p < 0.03).

This entry was posted in Pulmonary function and tagged antibiotics, evidence-based data, guidelines, infection control, Institute for Healthcare Improvement, intensive care, prevention of hospital-acquired pneumonia, ventilator-associated pneumonia.
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