Elsevier

Clinics in Perinatology

Volume 37, Issue 3, September 2010, Pages 629-643
Clinics in Perinatology

Strategies to Prevent Ventilator-Associated Pneumonia in Neonates

https://doi.org/10.1016/j.clp.2010.05.003Get rights and content

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Epidemiology

The exact rate of neonatal VAP is difficult to establish, because radiographic identification of pneumonia is difficult, especially among neonates with significant underlying lung disease, and diagnostic procedures commonly used in adults are rarely used in the neonatal intensive care unit (NICU). Differences in study methodology and case mix also influence the reported incidence of neonatal VAP.9 National Nosocomial Infections Surveillance system data from 2004 showed that VAP rates for

Pathogenesis

VAP occurs when bacterial, fungal, or viral pathogens enter the normally sterile lower respiratory tract and lung parenchyma. Under normal circumstances, anatomic barriers, cough reflexes, tracheobronchial secretions, mucociliary lining, cell-mediated and humoral immunity, and the phagocytic system of the alveolar macrophages and neutrophils protect the lung parenchyma from infection. If these defenses are impaired, absent, or overcome by a high inoculum of organisms or those of unusual

Microbiology

Staphylococcus aureus and gram-negative organisms (Pseudomonas aeruginosa, Eschericha coli, Klebsiella pneumoniae, Enterobacter sp, and Acinetobacter sp) are the most common pathogens responsible for VAP in adults and pediatric patients. Apisarnthanarak and colleagues17 noted gram-negative organisms in 94% of tracheal aspirates from neonates with VAP (Table 1). Multiple organisms were recovered from airway secretions in 58% of cases, and S aureus was recovered from approximately 25% of cases.

Diagnosis and treatment

The major controversy regarding VAP in neonates is the criteria used to establish the diagnosis.41 Stringent clinical criteria to define VAP have been developed by the CDC and the National Hospital Safety Network (NHSN). Criteria include mechanical ventilation within 48 hours of onset of suspected VAP; worsening gas exchange with an increase in oxygen or ventilatory requirements; 2 or more chest radiographs that show new infiltrates, consolidation, cavitation, or pneumatoceles; and at least 3

Preventing VAP

The CDC53 and American Thoracic Society54 have published guidelines for the prevention of health care-associated pneumonia. Several studies have shown a reduction in VAP after the guidelines were implemented into a bundle of interventions that were implemented as a single intervention.55, 56, 57, 58, 59 The power of the bundle is that it brings together several evidence-based practices that individually improve care but when applied together, may result in an even greater improvement in the

Summary

Table 2 summarizes interventions that have been shown to effectively reduce VAP in adults and neonates. Potential interventions for inclusion in a neonatal VAP prevention bundle, which have not been evaluated in neonates but seem biologically plausible with good safety profiles, are also given. Fig. 3 summarizes how practical preventative interventions relate to the steps in the pathogenesis of VAP. Improved diagnostic criteria and surveillance techniques for VAP in the neonatal population need

Acknowledgments

I would like to thank Mary O'Brien for her help with the preparation of the manuscript.

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      Moreover, differentiating pneumonia from underlying chronic lung disease from radiographs of LBW infants is difficult.123 Bronchoalveolar lavage (BAL) samples, or those taken from a protected specimen brush, are invasive tests used to diagnose VAP in adults.124 Given the small size of the airways, these tests are impractical in infants.

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