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Background: We report the process implemented in our institution by a task force focused on the reduction of ventilator-associated pneumonia (VAP)., Methods: Retrospective cohort study of all adults admitted to one of our 4 adult ICUs, intubated on invasive mechanical ventilation. We implemented a ventilator bundle in April of 2007; we report the incidence of VAP in 2008, and, after adjustment in the process (oral care performed by respiratory therapists), the incidence in 2009. The primary outcome was reduction of the microbiologically confirmed VAP rate over a 2 year period. Other outcomes were duration of mechanical ventilation, antibiotic days, ICU and hospital stay, and mortality., Results: During the study period, 2,588 patients received invasive mechanical ventilation in the adult ICUs. The VAP rate during 2008 was 4.3/1,000 ventilator days, and the 2009 rate was 1.2/1,000 ventilator days. The 2008 to 2009 VAP rate ratio was significantly greater than 1 (rate ratio 3.6, 95% CI 1.8-8.0, P < .001). Antibiotic days were less in 2009 versus 2008 (Hodges-Lehmann estimate of difference between 2008 and 2009, 1.0, 95% CI 0.0-1.0, P = .002). The median stay in the ICU was unchanged, and in the hospital was decreased in 2009 (Hodges-Lehmann estimate of difference between 2008 and 2009, 1.0, 95% CI 0.0-1.0, P < .001). The hospital mortality was 26.1%, and there was no difference between the 2 years. Adherence with the ventilator bundle was above 92% during the study period, but the oral care adherence improved from 33% to 97% after respiratory therapists assumed oral care., Conclusions: Reduction of the incidence of VAP occurred with an intervention that included respiratory therapists doing oral care in patients receiving invasive mechanical ventilation. Oral care done by respiratory therapists may be associated with reduction of VAP.

A quadruplex real-time (RT) qPCR assay for the detection and quantification in 4h of Staphylococcusaureus, Pseudomonasaeruginosa, Acinetobacterbaumannii and Stenotrophomonasmaltophilia directly from bronchoalveolar lavage specimens was developed. The specificity of the assay was 100% for all four species., (2010 Elsevier B.V. All rights reserved.)

Objectives: To characterize the current economic burden of ventilator-associated pneumonia (VAP) and to determine which services increase the cost of VAP in North American hospitals., Design and Setting: We performed a retrospective, matched cohort analysis of mechanically ventilated patients enrolled in the North American Silver-Coated Endotracheal Tube (NASCENT) study, a prospective, randomized study conducted from 2002 to 2006 in 54 medical centers, including 45 teaching institutions (83.3%)., Methods: Case patients with microbiologically confirmed VAP (n = 30)were identified from 542 study participants with claims data and were matched by use of a primary diagnostic code, and subsequently by the Acute Physiology and Chronic Health Evaluation II score, to control patients without VAP (n = 90). Costs were estimated by applying hospital-specific cost-to-charge ratios based on all-payer inpatient costs associated with VAP diagnosis-related groups., Results: Median total charges per patient were $198,200 for case patients and $96,540 for matched control patients (P < .001); corresponding median hospital costs were $76,730 for case patients and $41,250 for control patients (P = .001). After adjusting for diagnosis-related group payments, median losses to hospitals were $32,140 for case patients and $19,360 for control patients (P = .151). The median duration of intubation was longer for case patients than for control patients (10.1 days vs 4.7 days; P < .001), as were the median duration of intensive care unit stay (18.5 days vs 8.0 days; P < .001) and the median duration of hospitalization (26.5 days vs 14.0 days; P < .001). Examples of services likely to be directly related to VAP and having higher median costs for case patients were hospital care (P < .05) and respiratory therapy (P < .05)., Conclusions: VAP was associated with increased hospital costs, longer duration of hospital stay, and a higher number of hospital services being affected, which underscores the need for bundled measures to prevent VAP., Trial Registration: NASCENT study ClinicalTrials.gov Identifier: NCT00148642.

Objective: To elucidate the mechanism of action of the silver-coated endotracheal tube in models of the early pathogenesis of ventilator-associated pneumonia., Design: Open-labeled, prospective, controlled, sequentially conducted, preclinical studies, and in vitro assessment of tubes from patients., Setting: Microbiology laboratory of a device manufacturer, animal research facility of a university, and a tertiary medical center., Interventions: Endotracheal tubes were similar except for the silver coating. In the 21-day in vitro elution model, tube samples were incubated in saline solution at 37.8 degrees C. In the in vitro adherence model, coated and uncoated tubes were exposed to 21 respiratory isolates of radiolabeled microorganisms for 2-4 hrs. In the animal model, 12 healthy white rabbits were intubated for 16 hrs with noncuffed silver-coated or uncoated tubes and challenged with buccal administration of Pseudomonas aeruginosa. In the in vitro assessment, tubes from 16 patients underwent quantitative culture assessment and qualitative confocal laser scanning microscopy., Measurements and Main Results: After in vitro incubation, the mean residual silver concentration was 2.6 microg/cm, confirming that the coating was not entirely depleted. In vitro adherence to the silver-coated endotracheal tube was less than that of the uncoated tube for 12 of 21 isolates and equivalent for seven. For example, adherence to the silver-coated endotracheal tube was reduced >90% for all five isolates of P. aeruginosa (p < .05). In rabbits, P. aeruginosa colonization on the silver-coated endotracheal tube was reduced 99.9% compared with that on the uncoated tube (p < .0001); colonization in the tracheal and lung tissue was reduced > or =99% (p < .05). In the in vitro assessment, pathogens were detected on none of nine silver-coated tubes from patients and three of seven control tubes (p > .05)., Conclusions: : The collective findings of this series of studies demonstrated that the silver-coated endotracheal tube was active in models designed to mimic the early pathogenesis of ventilator-associated pneumonia.

Context: Ventilator-associated pneumonia (VAP) causes substantial morbidity. A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation., Objective: To determine whether a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP., Design, Setting, and Participants: Prospective, randomized, single-blind, controlled study conducted in 54 centers in North America. A total of 9417 adult patients (> or = 18 years) were screened between 2002 and 2006. A total of 2003 patients expected to require mechanical ventilation for 24 hours or longer were randomized., Intervention: Patients were assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes, similar except for a silver coating on the experimental tube., Main Outcome Measures: Primary outcome was VAP incidence based on quantitative bronchoalveolar lavage fluid culture with 10(4) colony-forming units/mL or greater in patients intubated for 24 hours or longer. Other outcomes were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality, and adverse events., Results: Among patients intubated for 24 hours or longer, rates of microbiologically confirmed VAP were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4%-6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7%-9.7%) (P = .03) in the group receiving the uncoated tube (all intubated patients, 3.8% [37/968; 95% CI, 2.7%-5.2%] and 5.8% [56/964; 95% CI, 4.4%-7.5%] [P = .04]), with a relative risk reduction of 35.9% (95% CI, 3.6%-69.0%; all intubated patients, 34.2% [95% CI, 1.2%-67.9%]). The silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005). No statistically significant between-group differences were observed in durations of intubation, intensive care unit stay, and hospital stay; mortality; and frequency and severity of adverse events., Conclusion: Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube., Trial Registration: clinicaltrials.gov Identifier: NCT00148642.

Objective: Our objective was to compare the results of a blind lavage vs a bronchoscopic-guided bronchoalveolar lavage for the etiologic diagnosis of ventilator-associated pneumonia (VAP)., Design: Prospective study in consecutive patients with high probability of VAP. Every patient underwent both procedures, in a formally randomized fashion. The interpretation of quantitative cultures was done in a blind fashion., Setting: Single center study, with a 20 bed medical and surgical Intensive Care Unit of the University Hospital in Monterrey, Mexico., Patients: Twenty-five patients with high probability of VAP., Interventions: Every patient underwent blind bronchoalveolar lavage with a modified nasogastric tube, and a bronchoscopic-guided bronchoalveolar lavage., Results: Twenty-one patients underwent both procedures. Four patients were excluded due to contamination of the cultures. The quantitative cultures were compared in a paired fashion. Only two patients had discordant cultures. The correlation coefficient between the number of colonies was very high, r=0.90 (95% confidence interval [CI], 0.77-0.96; p=0.0001)., Conclusions: The blind bronchoalveolar lavage with a modified nasogastric tube is a valuable tool for the identification of etiologic agent in VAP, particularly when trained bronchoscopists or the necessary resources for bronchoscopic-guided bronchoalveolar lavage are not readily available.