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Annotated Bibliography: Prevention of Ventilated Associated Pneumonia in the NICU population
Holy Family University
Ventilator associated pneumonia otherwise known as VAP continues to be a serious problem in neonatal units. VAP is defined as the nosocomial pneumonia which is developed after 48 hours after the initiation of mechanical ventilation. (Tan et al,2014). VAP is also the second most prevalent hospital acquired infection in the U.S.(Thibeau and Bourdreaux,2013). Prevention of VAP has been a frequent goal of quality improvement projects especially since hospital acquired infections are linked to decreased reimbursement rates. The patients in neonatal intensive care are at increased risk for VAP. In addition, diagnostic protocols are different for neonates thus creating challenges and preventative measures may also vary.
Tan,B.,Zhang,F.,Huang,Y.,Gao,Y.,Lui,Y. and Qui,J. (2014). Risk factors for ventilator-associated pneumonia in the neonatal intensive care unit: A meta-analysis of observational studies. European Journal of Pediatrics, 173,427-434.
The researchers of this journal article identified 10 risk factors from a literature review of 8 studies. The meta-analysis concluded that the risk factors for neonatal VAP were length of stay, reintubation, enteral feeding, mechanical ventilation, transfusion, low birth weight, prematurity, parental nutrition, bronchopulmonary dysplasia, and tracheal intubation. (Tan et al,2014). The reasoning behind researching several studies was that previous research provided inconsistent results, they felt that the larger sample size of several studies would be more accurate. (Tan et al,2014). They also set up certain criteria of which groups to include age< 28 days old and specific diagnostic criteria based on CDC guidelines. (Tan et al,2014). They utilized studies from different countries as well as different types of research methods. (Tan et al,2014). The article provided detailed descriptions of research methodologies utilized and seemed to be very unbiased. The risk factors identified show the majority of the NICU population is at risk for VAP, therefore continuous quality improvement in this area is a necessity.
Gibbs, K. and Holzman,I. (2012). Endotracheal Tube: Friend or Foe? Bacteria, the Endotracheal Tube, and the Impact of Colonization and Infection. Seminars in Perinatology 36,pp.454-461.
Gibbs and Holzman ,(2012) examine the latest research on VAP in the NICU population, which illustrates the challenges that are faced when trying to prevent and treat this hospital acquired infection. Intubated neonates have an increased incidence of VAP, bacterial colonization occurs shortly after birth, and microbes adhere to the endotracheal tube forming a biofilm which promotes persistent colonization and infection. (Gibbs and Holzman,2012). This type of infection has also been implicated in the development of chronic conditions of the neonate such as bronchopulmonary dysplasia and subglottic stenosis. (Gibbs and Holzman,2012). To diagnosis VAP a variety of culture techniques have been studied but few are reported in neonates. (Gibbs and Holzman,2012). Furthermore, the CDC has no specific diagnostic criteria for infants under 1 year. (Gibbs and Holzman,2012). Gibbs and Holzman (2012), discuss alternative diagnostic techniques that might be used for infants such as blind bronchoaleovar lavage and biomarkers that measure the neutrophil response. After diagnosis treatment becomes complicated, most infections are polymicrobal, it’s difficult to differentiate between infection versus colonization and antibiotic resistance is an ongoing problem. (Gibbs and Holzman,2012). The
article provided a large overview of this disease, confirming that while endotracheal tubes have saved lives in the NICU, they are not without risks.
Weber,C.(2016). Applying adult ventilator-associated pneumonia bundle evidence to the ventilated neonate. Advances in Neonatal Care,16(3), Pp. 178-189.
Research has focused on prevention of VAP in the adult population. In 2004, the CDC published recommendations stating that combining individual strategies also known as a bundle significantly reduces VAP in adults. (Weber,2016). Since some of the same principles that put adults at risk may also be applied to infants, combined approaches for prevention may also be beneficial for infants. (Weber,2016). These include hand hygiene and closed suctioning to prevent cross contamination of bacteria, elevating the head of the bed to prevent aspiration of gastrointestinal secretions, oral care to prevent bacterial colonization in the oral cavities and not routinely instilling saline during suctioning which can dislodge bacterial colonies. (Weber,2016). Further studies are need to be conducted to determine the successfulness of these techniques in neonates. (Weber,2016). The usefulness of applying adult proven VAP prevention bundles to neonates may prove to be lifesaving in this population. The interventions are simple allowing nursing compliance to be easily achieved.
Thibeau,S. and Boudreaux, C. (2013). Exploring the use of mothers ‘own milk as oral care for mechanically ventilated very low-birth-weight preterm infants. Advances in Neonatal Care,13(3), pp.190-197.
Mother’s own milk can be considered a natural oral care product in VAP prevention because it contains both healthy bacteria and immunological properties. (Thibeau and Bourdreaux,2013). A study was conducted on preterm infants to determine if using breast milk for oral care would reduce the incidence of VAP in preterm infants weighing less than 1500gm. (Thibeau and Bourdreaux,2013). This method of oral care was introduced into the VAP bundle at a level 3 NICU and nurses were instructed to swab the infants mouth with breast milk every 4 hours.(Thibeau and Bourdeaux,2013).Comparison was made to previous oral care without breastmilk. Results were determined by number of ventilated days, positive tracheal aspirates and positive blood cultures. (Thibeau and Bourdreaux ,2013). According to Tribeau and Bourdreaux, (2013) the study did not provide any statistically significant differences between the incidence of infection from the infants who received breast milk for oral care. The intervention was found to be safe practice. (Tribeau and Bourdreaux,2013). The use of breastmilk for oral care even if it has not been proven to prevent VAP may still have other helpful benefits such as promoting parent infant bonding and promoting positive infant oral stimulation. Further research in this area needs to be explored.
Ryan,R.,Wilding,G.,Wynn,R.,Welliver,R.,Holm,B. and Leach.(2011) Effect of enhanced utravoilet germicidal irradiation in the heating ventilation and air conditioning system on ventilated associated pneumonia in a neonatal intensive care unit. Journal of Perinatology 31, pp.607-614.
This study looked at the relationship between the environment and the incidence of VAP. The concept of environmental manipulation is an old one introduced by Florence
Nightingale. Rates of VAP and positive tracheal aspirates were tracked along with the presence bacteria in the HVAC system and surfaces in the NICU pre and post instillation of an enhanced ultraviolet germicidal irradiation system,eUVGI, known as Pathogen Control System in the NICU’s HVAC system.(Ryan et al,2011). This type of system is commonly used in TB clinics and operating rooms to reduce dissemination of airborne infections. (Ryan et al,2011). The bacteria found in the HVAC system was similar to both the bacteria found on the NICU surfaces and tracheal aspirates of the babies. (Ryan et al,2011). After installation of the eUVGI the incidence of VAP was significantly decreased from 74% to 44% over an 18-month period. (Ryan et al,2011). Although the installation of the eUVGI was probably costly this proved to be cost effective with better outcomes.
As new knowledge emerges in prevention of VAP in this population quality measures will help determine both response and compliance. Preventive measures to decrease the costly effects of VAP are necessary for improving outcomes of ventilated patients of all ages but especially the neonates who are at increased risk of this nosocomial infection. Nurses have an active role in reduction of and prevention of VAP, but hospitals also play a role in prevention.
Running Head: ANNOTATED BIBLIOGRAPHY-VAP 1
4 be beneficial for infants. (Weber,2016). These include hand hygiene and closed suctioning to prevent cross contamination of bacteria, elevating the head of the bed to prevent aspiration of gastrointestinal secretions, oral care to prevent bacterial colonization in the oral cavities and not routinely instilling saline during suctioning which can dislodge bacterial colonies. (Weber,2016). Further studies are need to be conducted to determine the successfulness of these techniques in neonates. (Weber,2016). The usefulness of applying adult proven VAP prevention bundles to neonates may prove to be lifesaving in this population. The interventions are simple allowing nursing compliance to be easily achieved.
As new knowledge emerges in prevention of VAP in this population quality measures will help determine both response and compliance. Preventive measures to de