Strategies to Prevent Ventilator-Associated Pneumonia, Ventilator-Associated Events, and Nonventilator Hospital-Acquired Pneumonia in Acute-Care Hospitals
Publication Date: May 20, 2022
Last Updated: November 15, 2023
Recommendations
Recommendations to Prevent VAP in Adult Patients (Table 1)
Essential Practices: interventions with little risk of harm and that are associated with decreases in duration of mechanical ventilation, length of stay, mortality, antibiotic utilization, and/or costs
1. Avoid intubation and prevent reintubation if possible.
- Use high flow nasal oxygen or non-invasive positive pressure ventilation (NIPPV) whenever safe and feasible.
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2. Minimize sedation.
- Minimize sedation of ventilated patients whenever possible.
- Preferentially use multimodal strategies and medications other than benzodiazepines to manage agitation.
- Utilize a protocol to minimize sedation.
- Implement a ventilator liberation protocol.
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3. Maintain and improve physical conditioning. Provide early exercise and mobilization. (Moderate)
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4. Elevate the head of the bed to 30–45ºa. (Low)
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5. Provide oral care with toothbrushing but without chlorhexidine. (Moderate)
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6. Provide early enteral rather than parenteral nutrition. (High)
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7. Change the ventilator circuit only if visibly soiled or malfunctioning (or per manufacturers’ instructions). (High)
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Additional Approaches: may decrease duration of mechanical ventilation, length of stay, and/or mortality in some populations but not in others, and may confer some risk of harm in some populations.
1. Consider using selective decontamination of the oropharynx and digestive tract to decrease microbial burden in ICUs with low prevalence of antibiotic resistant organisms. Antimicrobial decontamination is not recommended in countries, regions, or ICUs with high prevalence of antibiotic-resistant organisms. (High)
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Additional Approaches: may lower VAP rates, but current data are insufficient to determine their impact on duration of mechanical ventilation, length of stay, and mortality.
1. Consider utilizing endotracheal tubes with subglottic secretion drainage ports to minimize pooling of secretions above the endotracheal cuff for patients likely to require >48–72 hours of intubation. (Moderate)
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2. Consider early tracheostomy. (Moderate)
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3. Consider post-pyloric feeding tube placement in patients with gastric feeding intolerance or at high risk for aspiration. (Moderate)
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Approaches that Should Not be Considered a Routine Part of VAP Prevention
1. Oral care with chlorhexidine. (Moderate)
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2. Probiotics. (Moderate)
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3. Ultrathin polyurethane endotracheal tube cuffs. (Moderate)
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4. Tapered endotracheal tube cuffs. (Moderate)
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5. Automated control of endotracheal tube cuff pressures. (Moderate)
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6. Frequent cuff pressure monitoring. (Moderate)
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7. Silver coated endotracheal tubes. (Moderate)
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8. Kinetic beds. (Moderate)
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9. Prone positioning.a (Moderate)
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10. Chlorhexidine bathing.a (Moderate)
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11. Stress ulcer prophylaxis. (Moderate)
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12. Monitoring residual gastric volumes. (Moderate)
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13. Early parenteral nutrition. (Moderate)
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Unresolved Issues
- Closed/in-line endotracheal suctioning.
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a May be indicated for reasons other than VAP prevention.
Recommendations to Prevent VAP in Preterm Neonates (Table 2)
Essential Practices: confer minimal risk of harm and may lower VAP and/or PedVAE rates
1. Use non-invasive positive pressure ventilation in selected populations. (High)
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2. Minimize the duration of mechanical ventilation. (High)
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3. Assess readiness to extubate daily. (Low)
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4. Manage patients without sedation whenever possible. (Low)
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5. Avoid unplanned extubation. (Low)
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6. Avoid reintubation by using nasal continuous positive airway pressure (CPAP), NIPPV, or high flow nasal cannula in the post-extubation period. (High)
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7. Provide regular oral care with sterile water. (Low)
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8. Minimize breaks in the ventilator circuit. (Low)
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9. Change the ventilator circuit only if visibly soiled or malfunctioning (or per manufacturer’s instructions). (Low)
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10. Use caffeine therapy to facilitate extubation. (High)
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Additional Approaches: minimal risks of harm, but impact on VAP and VAE rates is unknown
1. Lateral recumbent positioning. (Low)
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2. Reverse Trendelenberg positioning. (Low)
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3. Closed/in-line suctioning systems. (Low)
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4. Oral care with maternal colostrum. (Moderate)
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Approaches that Should Not be Considered a Routine Part of VAP Prevention
1. Regular oral care with antiseptics. (Low)
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2. Histamine-2 receptor antagonists. (Moderate)
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3. Prophylactic broad-spectrum antibiotics. (Moderate)
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4. Daily spontaneous breathing trials. (Low)
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5. Daily sedative interruptions. (Low)
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6. Prophylactic probiotics or synbiotics. (Low)
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Unresolved Issues
- Endotracheal tubes with subglottic secretion drainage ports.
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- Silver-coated endotracheal tubes.
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Recommendations to Prevent VAP in Pediatric Patients (Table 3)
Essential Practices: confer minimal risk of harm and some data suggest that they may lower VAP rates, PedVAE rates, and/or duration of mechanical ventilation.
1. Avoid intubation.
- Use noninvasive positive pressure ventilation (NIPPV) or high-flow oxygen by nasal cannula whenever safe and feasible.
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2. Minimize duration of mechanical ventilation
- Assess readiness to extubate daily using spontaneous breathing trials in patients without contraindications.
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- Take steps to minimize unplanned extubations and reintubations.
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- Avoid fluid overload.
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3. Provide regular oral care (i.e., toothbrushing or gauze if no teeth). (Low)
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4. Elevate the head of the bed unless medically contraindicated. (Low)
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5. Maintain ventilator circuits:
- Change ventilator circuits only when visibly soiled or malfunctioning (or per manufacturer’s instructions).
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- Remove condensate from the ventilator circuit frequently and avoid draining the condensate toward the patient.
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6. Endotracheal tube selection and management.
- Use cuffed endotracheal tubes.
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- Maintain cuff pressure and volume at the minimal occlusive settings to prevent clinically significant air leaks around the endotracheal tube, typically 20–25 cm H2O. This “minimal leak” approach is associated with lower rates of postextubation stridor.
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- Suction oral secretions before each position change.
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Additional Approaches: minimal risks of harm and some evidence of benefit in adult patients but data in pediatric populations are limited.
1. Minimize sedation. (Moderate)
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2. Use endotracheal tubes with subglottic secretion drainage ports for patients ≥10 years of age. (Low)
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3. Consider early tracheotomy. (Low)
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Approaches that Should Not be Considered a Routine Part of VAP Prevention
1. Prolonged systemic antimicrobial therapy for ventilator-associated tracheitis. (Low)
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2. Selective oropharyngeal or digestive decontamination. (Low)
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3. Probiotic prophylaxis. (Low)
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4. Oral care with antiseptics such as chlorhexidine. (Moderate)
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5. Stress ulcer prophylaxis. (Low)
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6. Silver-coated endotracheal tubes. (Low)
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Unresolved Issues
- Closed/in-line suctioning.
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Strategies to Prevent Ventilator-Associated Pneumonia, Ventilator-Associated Events, and Nonventilator Hospital-Acquired Pneumonia in Acute-Care Hospitals
Authoring Organizations
Infectious Diseases Society of America
Society for Healthcare Epidemiology of America
Publication Month/Year
May 20, 2022
Last Updated Month/Year
February 12, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014.
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Emergency care, Hospital, Operating and recovery room
Intended Users
Epidemiology infection prevention, nurse, nurse practitioner, physician, physician assistant
Scope
Management, Prevention
Diseases/Conditions (MeSH)
D053717 - Pneumonia, Ventilator-Associated, D000077299 - Healthcare-Associated Pneumonia
Keywords
hospital-acquired pneumonia, ventilator-associated pneumonia, HAP, VAP
Source Citation
Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022 May 20:1-27. doi: 10.1017/ice.2022.88. Epub ahead of print. PMID: 35589091.
Methodology
Number of Source Documents
399
Literature Search Start Date
January 1, 2012
Literature Search End Date
August 1, 2021