Neonatal Ventilator Associated Pneumonia: A Quality Improvement Initiative Focusing on Antimicrobial Stewardship

Abstract

Background and Aims: Neonatal ventilator associated pneumonia (VAP) is a common nosocomial infection and a frequent reason for empirical antibiotic therapy in NICUs. Nonetheless, there is no international consensus regarding diagnostic criteria and management. In a first step, we analyzed the used diagnostic criteria, risk factors and therapeutic management of neonatal VAP by a literature review. In a second step, we aimed to compare suspected vs. confirmed neonatal VAP episodes in our unit according to different published criteria and to analyze interrater-reliability of chest x-rays. Additionally, we aimed to evaluate the development of VAP incidence and antibiotic use after implementation of multifaceted quality improvement changes regarding antimicrobial stewardship and infection control (VAP-prevention-bundle, early-extubation policy, antimicrobial stewardship rounds).Methods: Neonates until 44 weeks of gestation with suspected VAP, hospitalized at our level-III NICU in Lucerne from September 2014 to December 2017 were enrolled. VAP episodes were analyzed according to 4 diagnostic frameworks. Agreement regarding chest x-ray interpretation done by 10 senior physicians was assessed. Annual incidence of suspected and confirmed neonatal VAP episodes and antibiotic days were calculated and compared for the years 2015, 2016, and 2017.Results: 17 studies were identified in our literature review. Overall, CDC-guidelines or similar criteria, requesting radiographic changes as main criteria, are mostly used. Comparison of suspected vs. confirmed neonatal VAP episodes showed a great variance (20.4 vs. 4.5/1,000 ventilator-days). The interrater-reliability of x-ray interpretation was poor (intra-class correlation 0.25). Implemented changes resulted in a gradual decline in annual VAP incidence and antibiotic days from 2015 compared with 2017 (28.8 vs. 7.4 suspected episodes/1,000 ventilator-days, 5.5 vs. 0 confirmed episodes/1,000 ventilator-days and 211 vs. 34.7 antibiotic days/1,000 ventilation-days, respectively).Conclusion: The incidence of suspected VAP and concomitant antibiotic use is much higher than for confirmed VAP, therefore inclusion of suspected episodes should be considered for accurate evaluation. There is a high diagnostic inconsistency and a low reliability of interpretation of chest x-rays regarding VAP. Implementation of combined antimicrobial stewardship and infection control measures may lead to an effective decrease in VAP incidence and antibiotic use.

Device associated infections among neonates in neonatal intensive care units: a single unit survey study in Cairo, Egypt

“…The current study found a VAP rate of 5.7/1000 ventilator days in NICU, which is concomitant with neonatal VAP rate in the United States (4-6.5/1000 DD) and in other countries like Rio de Janiro and lower than the neonatal VAP rate in the International Health careassociated Infection Control Consortium (INICC) report which was 8.95/1000 DD and much lower than another Egyptian study which showed 34.2 episodes/1000 ventilator days. [17][18][19] This low rate observed in this study could be attributed to the routine strict implementation of VAP prevention bundle in CUSPH, NICU unit. 20 This study found that DAI mortality rate was 25%, this finding goes in harmony with Kasim et al, who studied nosocomial infections in NICUs, the authors found that mortality was significantly higher among infected neonates with VAP and CLABSI.…”

Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature Review

“…In January 2016, a VAP-working group was established and their elaborated care bundle was implemented in December 2016. The recommended rules were described by Goerens et al ( 27 ) as the following: “Hand hygiene before and after patient contact and handling respiratory equipment, wearing gloves when in contact with secretions, ventilator circuit changes every 14 days or when visibly soiled, oral care every 2-4 hours, head of bed elevation, draining ventilator condensate before repositioning of the patient, using endotracheal tube (ETT) with cuff, choosing size of the ETT carefully to reduce numbers of reintubation.”…”

Ventilator-associated pneumonia in neonates: the role of point of care lung ultrasound

“…Several modified criteria have been developed. However, comparison of agreement between four diagnostic criteria showed only moderate agreement [5].…”

“…However, interpreting radiographic changes in patients with underlying lung pathology and on mechanical ventilation can be challenging and comorbidities such as chronic lung disease (CLD) can obscure radiographic evidence of VAP [6,7]. Reliability of chest X-ray interpretation has been shown to be low for neonatal VAP [5].…”