The efficacy of VAP prophylaxis bundle

O.V. Ignatenko1,3, A.O. Bykov1,3, I.N. Tyurin2,3, E.B. Gelfand3, D.N. Protsenko1,3

1 Yudin city hospital, Moscow

2 Buyanov city hospital, Moscow

3 Department of anesthesiology and critical care medicine, Pirogov Russian National Research Medical University (RNRMU), Moscow

For correspondence: Denis Protsenko — MD, PhD, the Head of department of anesthesiology and critical care medicine, Pirogov Russian National Research Medical University, superintendent Yudin city hospital, Chief Anesthesiology and CCM Officer, Moscow; e-mail:

For citation: Ignatenko OV, Bykov AO, Tyurin IN, Gelfand EB, Protsenko DN. The efficacy of VAP prophylaxis bundle. Alexander Saltanov Intensive Care Herald. 2018;3:39–45.

DOI: 10.21320/1818-474X-2018-3-39-45

Objective: to evaluate efficacy of VAP prophylaxis bundle.

Methods: 79 ICU pts were included in RCT. The reason of invasive mechanical ventilation was the depression of consciousness due to stroke or head injury. The pts were randomized to VAP prophylaxis bundle group 1 or to standard care group 2. In first group we used bundle including filter and HME, special antimicrobial ventilator circuit, closed aspiration system and special oral hygiene system. The oral care performed 3 time per 24 hours with visual inspection, 0,05 % chlorhexidine solution washing, dental and gun cleaning, only closed system aspiration.

Results: VAP prophylaxis bundle decrease early onset VAP — 6.6 and 33 % in 1 and 2 groups respectively (p = 0.00167), increase VAP free-day — 7.5 ± 4.6 day in 1 group and 5.3 ± 6.5 day, (p = 0.00182) in group 2; decrease severity of VAP — CPIS on day 7 was 5.96 ± 3.2 and 7.2 ± 2.43 in 1 and 2 groups (p = 0.046), P/F on day 7 — 304.84 ± 22 and 255.9 ± 43 in 1 and 2 groups (p = 0.001).

The multivariate analysis show that oral care protocol was he most significant part of bundle (OR 0.21, 0.15–0.61 95 % CI; p = 0.00014). Microbiology data show decrease of CFU colonization Klebsiella pneumoniae from 106 to 104 (p < 0.001), Streptococcus pneumoniae from 107 to 103 (p < 0.001), MRSA from 105 to 103 (p < 0.001), Proteus mirabilis from 107 to 103 (p < 0.001).

Conclusions: VAP prophylaxis bundle decrease “early onset” VAP, severity of VAP, increase VAP free day.

Keywords: NP, VAP, ICU, VAP prophylaxis

Received : 07.08.2018


  1. Фокин А.А., Галкин Д.В., Мищенко В.М. и др. Уроки эпидемиологических исследований нозокомиальных инфекций в России. Клин. микробиол. и антимикроб. химиотер. 2008; 10(1): 4–14. [Fokin A.A., Galkin D.V., Mishchenko V.M. et al. Uroki ehpidemiologicheskih issledovaniĭ nozokomial’nyh infekcii v Rossii. Klin. mikrobiol. I antimikrob. himioter. 2008; 10(1): 4–14. (In Russ)]
  2. Annual epidemiological report. European Centre for Disease Prevention and Control. 2008.
  3. Sydnor E., Perl T. Hospital epidemiology and infection control in acute-care settings. Clin. Microbiology Reviews. 2011; 24(1): 141–173.
  4. Cilloniz C. et al. Hospital-acquired pneumonia in ICU. Int. J. Intensive Care. 2013; 20(1): 18–23.
  5. Chalmers J. et al. Epidemiology, antibiotic therapy, and clinical outcomes in healthcare-associated pneumonia. Clinical Infectious Diseases. 2011; 53(2): 107–113.
  6. Pneumonia in adults: diagnosis and management. NICE guidelines [CG191]. Published date: December 2014.
  7. Rello J. et al. Epidemiology and outcomes of ventilator–associated pneumonia in large US database. Chest. 2002; 122: 2115– 2121.
  8. Гельфанд Б.Р., Белоцерковский Б.З., Милюкова И.А., Гельфанд Е.Б. Эпидемиология и нозологическая структура нозокомиальных инфекций в отделении реанимации и интенсивной терапии многопрофильного стационара. Инфекции в хирургии. 2014; 4: 24–36. [Gel’fand B.R., Belocerkovskij B.Z., Milyukova I.A., Gel’fand E.B. Ehpidemiologiya I nozologicheskaya struktura nozokomial’nyh infekcij v otdelenii reanimacii I intensivnoj terapii mnogoprofil’nogo stacionara. Infekcii v hirurgii. 2014; 4: 24–36. (In Russ)]
  9. Masterton R. et al. Guidelines for the management of hospital acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J. of Antimicrobial Chemotherapy. 2008; 62(1): 5–34.
  10. Hunter J. Ventilator associated pneumonia. BMJ. 2012; 344: e3325.
  11. Kieninger A., Lipsett P. Hospital-acquired pneumonia: pathophysiology, diagnosis, and treatment. Surg. Clin. North. Am. 2009; 89: 439–461.
  12. Kalanuria A.A., Mirski M., Ziai W. VAP in ICU. Annual update in Intensive Care and Emergency Med. 2014: 65–77.
  13. Chastre J., Fagon J. Ventilator-associated pneumonia. Am. J. Respir. Crit. Care Med. 2002; 165: 867–903.
  14. Bonten M. VAP: preventing the inevitable. Clin. Infect. Dis. 2011; 52(1): 115–121.
  15. Klompas M. The paradox of ventilator-associated pneumonia prevention measures. Crit. Care. 2009; 13(5): 315.
  16. Bekaert M. et al. Attributive mortality of ventilator associated pneumonia. Am. J. Respir. Crit. Care Med. 2011; 184: 1133–1139.
  17. Coppadoro A. et al. Novel preventive strategies for ventilator-associated pneumonia. Crit. Care. 2012; 16: 210.
  18. Koff M.D., Corwin H.L., Beach M.L., et al. Reduction in ventilator associated pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program. J. Crit. Care. 2011; 26(5): 489–495.
  19. Нозокомиальная пневмония у взрослых. Российские национальные рекомендации. М.: Боргес, 2009. [Nozokomial’naya pnevmoniya u vzroslyh. Rossijskie nacional’nye rekomendacii. M.: Borges, 2009. (In Russ)]
  20. Санитарно-эпидемиологические требования к организациям, осуществляющим медицинскую деятельность. СанПин 2010. [Sanitarno-ehpidemiologicheskie trebovaniya k organizaciyam, osushchestvlyayushchim medicinskuyu deyatel’nost’. SanPin 2010. (In Russ)]
  21. Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. 2008.
  22. Labeau S.O., van de Vyver K., Brusselaers N. et al. Prevention of ventilator-associated pneumonia with oral antiseptics: A systematic review and meta-analysis. Lancet Infect. Dis. 2011; 11(11): 845–854.
  23. Silvestri L. et al. Effectiveness of oral Chlorhexidine on nosocomial pneumonia, causative micro-organisms and mortality in critically ill patients: a systematic review and meta-analysis. Minerva Anestesiol. 2014; 80: 805–820.
  24. Craven D.E. Epidemiology of ventilator-associated pneumonia. Chest. 2000; 117(4 Suppl. 2): 186S–187S.
  25. George D.L., Falk P.S., Wunderink R.G., et al. Epidemiology of ventilator-acquired pneumonia based on protected bronchoscopic sampling. Am. J. Respir. Crit. Care Med. 1998; 158(6): 1839–1847.
  26. Neuhauser M.M., Weinstein R.A., Rydman R., et al. Antibiotic resistance among gram-negative bacilli in US intensive care units: implications for fluoroquinolone use. JAMA. 2003; 289(7): 885–888.
  27. Robert R., Grollier G., Frat J.P., et al. Colonization of lower respiratory tract with anaerobic bacteria in mechanically ventilated patients. Intensive Care Med. 2003; 29(7):1062–1068.
  28. Drakulovic M.B., Torres A., Bauer T.T., et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999; 354(9193): 1851–1858.
  29. Shorr A.F., O’Malley P.G. Continuous subglottic suctioning for the prevention of ventilator-associated pneumonia: potential economic implications. Chest. 2001; 119(1): 228–235.
  30. Burns K.E., Meade M.O. Noninvasive ventilation reduced duration of mechanical ventilation and ICU stay more than conventional weaning. ACP J. Club. 2004; 140(2): 35.
  31. Kearns P.J., Chin D., Mueller L., et al. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit. Care Med. 2000; 28(6): 1742–1766.
  32. Collard H.R., Saint S., Matthay M.A. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann. Intern. Med. 2003; 138(6): 494–501.
  33. van Nieuwenhoven C.A., Buskens E., Bergmans D.C., et al. Oral decontamination is cost-saving in the prevention of ventilator-associated pneumonia in intensive care units. Crit. Care Med. 2004; 32(1): 126–130.
  34. Genuit T., Bochicchio G., Napolitano L.M., et al. Prophylactic chlorhexidine oral rinse decreases ventilator-associated pneumonia in surgical ICU patients. Surg. Infect. (Larchmt). 2001; 2(1): 5–18.
  35. Young P.J., Rollinson M., Downward G., Henderson S. Leakage of fluid past the tracheal tube cuff in a benchtop model. Br. J. Anaesth. 1997; 78(5): 557–562.
  36. Nardi G., Di Silvestre A.D., De Monte A., et al. Reduction in gram-positive pneumonia and antibiotic consumption following the use of a SDD protocol including nasal and oral mupirocin. Eur. J. Emerg. Med. 2001; 8(3): 203–214.
  37. Scannapieco F.A., Rethman M.P. The relationship between periodontal diseases and respiratory diseases. Dent. Today. 2003; 22(8): 79–83.
  38. El-Solh A.A., Pietrantoni C., Bhat A., et al. Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest. 2004; 126(5): 1575–1582.
  39. Yoneyama T., Yoshida M., Ohrui T., et al. Oral Care Working Group (2002) Oral care reduces pneumonia in older patients in nursing homes. J. Am. Geriatr. Soc. 2002; 50(3): 430–433.