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.
(High)
2737437
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.
(High)
2737437
3. Maintain and improve physical conditioning. Provide early exercise and mobilization. (Moderate)
2737437
4. Elevate the head of the bed to 30–45ºa. (Low)
2737437
5. Provide oral care with toothbrushing but without chlorhexidine. (Moderate)
2737437
6. Provide early enteral rather than parenteral nutrition. (High)
2737437
7. Change the ventilator circuit only if visibly soiled or malfunctioning (or per manufacturers’ instructions). (High)
2737437

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)
2737437

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)
2737437
2. Consider early tracheostomy. (Moderate)
2737437
3. Consider post-pyloric feeding tube placement in patients with gastric feeding intolerance or at high risk for aspiration. (Moderate)
2737437

Approaches that Should Not be Considered a Routine Part of VAP Prevention

1. Oral care with chlorhexidine. (Moderate)
2737437
2. Probiotics. (Moderate)
2737437
3. Ultrathin polyurethane endotracheal tube cuffs. (Moderate)
2737437
4. Tapered endotracheal tube cuffs. (Moderate)
2737437
5. Automated control of endotracheal tube cuff pressures. (Moderate)
2737437
6. Frequent cuff pressure monitoring. (Moderate)
2737437
7. Silver coated endotracheal tubes. (Moderate)
2737437
8. Kinetic beds. (Moderate)
2737437
9. Prone positioning.a (Moderate)
2737437
10. Chlorhexidine bathing.a (Moderate)
2737437
11. Stress ulcer prophylaxis. (Moderate)
2737437
12. Monitoring residual gastric volumes. (Moderate)
2737437
13. Early parenteral nutrition. (Moderate)
2737437

Unresolved Issues

  • Closed/in-line endotracheal suctioning.
()
2737437
a May be indicated for reasons other than VAP prevention.

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