Australasian Medical Journal [AMJ 2013, 6, 4, 178-182]

Incidence and risk factors of ventilator associated pneumonia in a tertiary care

hospital
MV Pravin Charles1, Joshy M Easow1, Noyal M Joseph1, M Ravishankar2, Shailesh Kumar1, Sivaraman
Umadevi1
1. Department of Microbiology and 2. Department of Anaesthesiology

Mahatma Gandhi Medical College and Research Institute, Pondicherry, India

RESEARCH independent risk factor for VAP.

Conclusion
VAP occurred in a sizeable number of patients on MV.
Please cite this paper as: Charles MVP, Joshy M Easow,
Chronic lung failure, H2 blockers usage, and supine head
Joseph NM, Ravishankar M, Kumar S, Umadevi S. Incidence
position were the risk factors associated with VAP.
and risk factors of ventilator associated pneumonia in a
Awareness about these risk factors can be used to inform
tertiary care hospital. AMJ 2013, 6, 4, 178-182.
simple and effective preventive measures.
http//dx.doi.org/10.4066/AMJ.2013.1627
Key Words
VAP; incidence; risk factors
Corresponding Author:
Dr. MV Pravin Charles, Background
Assistant Professor, Ventilator associated pneumonia (VAP) is a type of
Department of Microbiology,
nosocomial pneumonia which occurs in patients who
Mahatma Gandhi Medical College and Research Institute,
Pillaiyarkuppam, Pondicherry – 607 402 (India) receive mechanical ventilation (MV) via tracheal or
1
Email: [email protected] tracheostomy tube. Differences in VAP incidences have
been based on the antibiotic profile, ICU environment, and
2
the population of study. According to The National
Abstract Nosocomial Infection Surveillance Program the incidence of
3
VAP is 7.6 cases per 1000 patient ventilator days. The
Background 4,5
incidence of VAP ranges from 28-32%. This difference is a
Ventilator associated pneumonia (VAP) is a type of result of the diversity of diagnostic methods used.
nosocomial pneumonia associated with increased morbidity Development of VAP ≤ 96 hours of MV is classified as early
and mortality. Knowledge about the incidence and risk onset; a delay of more than 96 hours is termed as late
factors is necessary to implement preventive measures to 6
onset. Intubation alone is a risk factor for the development
reduce mortality in these patients. 7
of pneumonia among hospitalised patients. Both the host
Method and intervention associated risk factors increase the
A prospective study was conducted at a tertiary care 1
mortality among these patients. The end result is either
teaching hospital for a period of 20 months from November colonisation or aspiration of the respiratory contents with
2009 to July 2011. Patients who were on mechanical 8,9
potential pathogens. The mortality rate among these
ventilation (MV) for more than 48 hours were monitored at 6,10
patients ranges from 16-20%. A study of both incidence
frequent intervals for development of VAP using clinical and and risk factors was necessary to implement preventive
microbiological criteria until discharge or death. measures and thereby reduce mortality rate in these
Results patients.
Of the 76 patients, 18 (23.7%) developed VAP during their
ICU stay. The incidence of VAP was 53.25 per 1,000
Method
ventilator days. About 94% of VAP cases occurred within the
Study design
first week of MV. Early-onset and late-onset VAP was
A prospective study was conducted at a tertiary care
observed in 72.2% and 27.8%, respectively. Univariate
teaching hospital over a period of 20 months from
analysis showed chronic lung failure, H2 blockers usage, and
November 2009 to July 2011.
supine head position were significant risk factors for VAP.
Logistic regression revealed supine head position as an

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5
All patients admitted in the ICU who received MV were 1000 times diluted EA was interpreted as more than 10
11
included in the study. Patients who were mechanically CFU/ ml. The isolates were identified based on standard
12
ventilated for less than 48 hours and those who had bacteriological techniques.
developed pneumonia prior to initiation of MV were
excluded from the study. The study was approved by the Diagnosis
institute ethics committee. Informed consent was obtained VAP was diagnosed in patients who fulfilled both clinical
from the patient’s next of kin. and microbiological criteria. A clinical diagnosis was made
with the use of the modified Clinical Pulmonary Infection
Figure 1: Flowchart showing the inclusion and exclusion of Score (CPIS) based on six clinical assessments, each worth
13
patients zero to two points. VAP was confirmed microbiologically in
patients with quantitative endotracheal aspirate culture
5
indicative of ≥ 10 CFU/ml with a positive Gram stain (>10
Polymorphonuclear cells/ high power field and ≥ 1 bacteria/
14-16
oil immersion field).

Method of analysis
Results were expressed as mean± SD. Continuous variables
were compared using Student’s t test for normally
distributed variables. Univariate analysis with chi-square or
Fisher’s exact test was performed to compare the risk
factors in patients with and without VAP. Univariate results
were confirmed with logistic regression analysis using
statistics software (SPSS 16.0, SPSS Inc, Chicago, Illinois).
This was necessary to avoid producing spuriously significant
results with multiple comparisons. A stepwise approach was
used to enter new terms into the model with 0.05 as the
limit for their acceptance or removal. Results of the logistic
regression analyses were reported as estimated odd ratios
with their 95% confidence intervals. All p values < 0.05 were
considered statistically significant.

Results
During a 20-month period (November 2009 to July 2011),
Data collection
112 consecutive patients admitted to the ICU were
The following variables were collected: age, sex, provisional
prospectively evaluated. Of these, 36 (32.1%) were
diagnosis, date of hospital admission, and duration of MV.
excluded due to mechanical ventilation for less than 48
The patients included in this study were monitored at
hours. The remaining 76 (67.9%) patients who received MV
frequent intervals (every 48 hours) for the development of
for > 48 h were studied.
VAP using clinical and microbiological criteria till discharge
or death. The parameters such as fever, chest X-ray,
Of the 76 patients, 18 (23.7%) developed VAP during their
oxygenation, leukocytosis, and other risk factors were
ICU stay. Early onset VAP occurred in 13 (72.2%), while late
collected every 48 hours.
onset VAP was observed in the remaining 5 (27.8%)
patients. Ninety-four per cent (17 out of 18) of VAP cases
Microbiological methods
occurred within the first week of MV. The incidence of VAP
EA was serially diluted in sterile normal saline as 1/10,
was 53.25 per 1,000 ventilator day.
1/100, 1/1000 and 0.01 ml of 1/1000 dilution was
o
inoculated on 5% sheep blood agar. After incubation at 37 C
Of the 76 study patients, 56 were men (73.7%) and 20
in 5% CO2 incubator for 24 hours, colony count was
(26.3%) were women. The mean ± SD age of patients
completed and expressed as number of colony forming
receiving MV was 48.11 ± 18.2 years (range, 14 to 82 years).
units per ml (CFU/ml). The number of CFU/ ml is equal to
The comparison of the age and sex distribution of the
number of colonies on agar plate × dilution factor ×
patients with and without VAP is shown in Table 1. The
inoculation factor. Therefore, the presence of a single
most frequent cause of ICU admission was poisoning
colony on the blood agar after inoculating 0.01 ml of 1/

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(22.4%). There was no statistically significant difference in Univariate analysis indicated that chronic lung failure, use of
the distribution of the various primary illnesses in the H2 blockers, and supine head position were significantly
patients with and without VAP (Table 2). associated with VAP (Table 3). Selected risk factors were
entered into a logistic regression model to perform the
Table 1: Age and sex distribution of the patients with and multivariate analysis which revealed that supine head
without VAP position was an independent risk factor for VAP (Table 4).
Parameter Non-VAP VAP (n = 18) P value
(n = 58) (2-tailed) Table 4: Logistic regression analysis of the risk factors for
Age (mean ± SD) 48.2 ± 18.4 47.8 ± 17.8 0.94 VAP
Gender Estimated 95% confidence
Male 41 (70.7%) 15 (83.3%) 0.36 P value
Odds ratio interval
Female 17 (23.3%) 03 (16.7%)
Lower Upper

Table 2: Primary diagnosis of the study patients Chronic lung 6.12 0.07 0.85 44.12
failure
Primary diagnosis Non-VAP VAP P value
H2 blockers 4.42 0.07 0.87 22.40
(n = 58) (n = 18)
Supine head 5.00 0.02 1.17 21.24
Cardiovascular disease 9 (15.5) 4 (22.2) 0.49 position
CNS infections 4 (6.9) 1 (5.6) 1.00
Intra-abdominal 8 (13.8) 4 (22.2) 0.46
diseases Discussion
Neurological disorders 6 (10.3) - Ventilator associated pneumonia is a type of nosocomial
Poisoning 13 (22.4) 4 (22.2) 1.00
infection acquired in the ICU. We observed that the
Respiratory disease 12 (20.7) 4 (22.2) 1.00
incidence of VAP was about 23.7%, which is comparable to
Trauma 1 (1.7) 1 (5.6) 0.42
Other 5 (8.6) - the observations made in several other studies. In a study
conducted from four multidisciplinary intensive care units
4
Pseudomonas aeruginosa (33.3%) was the most common from Greece the incidence was reported to be 32%. In a
organism isolated from VAP patients. It was followed by evaluation made in Boston, VAP was reported at the rate of
17
Klebsiella pneumoniae (20.8%), Staphylococcus aureus 10.2% per 1000 ventilator days. Similarly Gupta A and
5
(8.3%), Candida albicans (8.3%), Escherichia coli (8.3%), coworkers, reported an incidence of 28.0%. In a study from
6
Acinetobacter baumannii (4.2%) and Stenotrophomonas South India the incidence was reported to be 18%.
maltophilia (4.2%).

Table 3: Univariate analysis of the risk factors for VAP

Risk factor Non-VAP VAP Relative risk (95% confidence P value
(n = 58) (%) (n = 18) (%) limits)

Chronic lung failure 2 (3.4) 4 (22.2) 3.33 (1.60 to 6.95) 0.0255

H2 blockers 34 (58.6) 16 (88.8) 4.16 (1.03 to 16.73) 0.0375
Supine head position 30 (51.7) 15 (83.3) 3.44 (1.09 to 10.90) 0.0349
Age ≥ 60 yrs 14 (24.1) 3 (16.7) 0.69 (0.23 to 2.12) 0.7473
Organ failure 4 (6.9) 3 (16.7) 1.97 (0.75 to 5.18) 0.3461
Abdomino-thoracic surgery 10 (17.2) 2 (11.1) 0.67 (0.18 to 2.53) 0.7199
ARDS 5 (8.6) 2 (11.1) 1.23 (0.35 to 4.29) 0.6667
Impaired consciousness 20 (34.5) 6 (33.3) 0.96 (0.41 to 2.27) 0.8457
Tracheostomy 2 (3.4) 1 (5.5) 1.43 (0.27 to 7.48) 0.5611
Nasogastric tube 49 (84.5) 15 (83.3) 0.94 (0.32 to 2.75) 1.0000
Steroids 5 (8.6) 1 (5.5) 0.69 (0.11 to 4.31) 1.0000
Emergency intubation 7 (12.1) 1 (5.5) 0.50 (0.08 to 3.27) 0.6716

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VAP is generally classified as early onset and late onset position, stress ulcer prophylaxis, surgery, burns, chronic
based on the time of onset of VAP. In our study, early onset renal failure, trauma, steroid therapy and duration of MV ≥
2,18
VAP occurred in 13 (72.2%) patients, while late onset VAP 5d were documented as risk factors in other studies. In
was observed in the remaining 5 (27.8%) individuals. Other another study, impaired consciousness, tracheostomy,
studies have reported early-onset VAP in almost half of all reintubation, emergency intubation, and nasogastric tube
18,19 6
VAP episodes. were found to be independent risk factors for VAP.
Awareness of these risk factors helps to overcome the
We observed that about 94% (17 out of 18) of VAP cases adverse effects of VAP.
occurred within the first week of mechanical ventilation.
Apostolopoulou et al also had documented that there was Conclusion
an increased risk of developing VAP during the first two VAP, an important nosocomial infection among the critically
weeks of MV. The increased risk is mainly attributed to the ill patients, requires purposeful study to reduce mortality.
interaction of several risk factors during the initial days of Good knowledge of VAP and its associated parameters is
4
MV. important. Despite the small sample size which is a
limitation of our study, our findings emphasize the
The patients who developed VAP in the present study were importance of the several risk factors for VAP. Further
admitted for various clinical disorders. There was no studies on incidence and risk factors can facilitate
significant association between the occurrence of VAP and knowledge translation activities about the disease and
the primary diagnosis of the patients, however the small thereby minimise the occurrence of VAP through the
number of patients in our study group could have resulted implemention of simple, low cost preventive measures.
in our failure to find significant associations in our Awareness about the various risk factors will aid in
subgroups. For example, in a similar study from South India, reduction of the morbidity and mortality associated with
patients with neurological disorders and CNS infections VAP.
were observed to be significantly predisposed for the
6
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