Paediatric Respiratory Reviews 20 (2016) 1016

Contents lists available at ScienceDirect

Paediatric Respiratory Reviews

Mini-Symposium: Ventilation Strategies in the Paediatric Intensive Care Unit

Ventilator Associated Pneumonia in Children

Ivy Chang, Andreas Schibler *
Paediatric Critical Care Research Group, Lady Cilento Childrens Hospital, South Brisbane QLD

EDUCATIONAL AIMS

The reader will come to appreciate that ventilator associated pneumonia:

 Is the second most common acquired infection in ventilated children

 Is associated with signicant morbidity and mortality
 Contributes signicantly to increase in health care burden and costs

A R T I C L E I N F O S U M M A R Y

Keywords: Ventilator associated pneumonia (VAP) is a common complication in mechanically ventilated children
Mechanical Ventilation
and adults. There remains much controversy in the literature over the denition, treatment and
Ventilator Induced Lung Injury
prevention of VAP. The incidence of VAP is variable, depending on the denition used and can effect up to
Infection Control
Paediatric Intensive Care 12% of ventilated children. For the prevention and reduction of the incidence of VAP, ventilation care
bundles are suggested, which include vigorous hand hygiene, head elevation and use of non-invasive
ventilation strategies. Diagnosis is mainly based on the clinical presentation with a lung infection
occurring after 48 hours of mechanical ventilation requiring a change in ventilator settings (mainly
increased oxygen requirement, a positive culture of a specimen taken preferentially using a sterile
sampling technique either using a bronchoscope or a blind lavage of the airways). A new inltrate on a
chest X ray supports the diagnosis of VAP. For the treatment of VAP, initial broad-spectrum antibiotics
should be used followed by a specic antibiotic therapy with a narrow target once the bacterium is
conrmed.
Crown Copyright 2015 Published by Elsevier Ltd. All rights reserved.

INTRODUCTION paediatric cardiothoracic surgical patients, VAP was associated

with an additional 3.7 days of mechanical ventilation with an
After blood stream infections [1], Ventilator Associated estimated cost of U$11,897 per episode [5]. Moreover, for each day
Pneumonia (VAP) is the second most frequently occurring spent in the paediatric cardiac intensive care unit as a newborn, the
nosocomial infection in Paediatric Intensive Care Unit (PICU), full scale IQ of a patient at 8 years of age falls by 1.4 points, and
accounting for up to 20% of all such infections [1,2]. VAP not only mathematical achievement by 1.6 points [6]. The accumulated
contributes to prolonged hospital length of stay and increased cost, socioeconomic cost for treatment of VAP therefore far exceeds the
but also to mortality and morbidity [3,4]. In a retrospective study of expenses associated with prevention of VAP, and highlights the
importance of instituting preventative measures to reduce the risk
of VAP [7,8]. There have been increasing numbers of publications in
* Corresponding author. Paediatric Intensive Care Staff Specialist, FCICM, recent years addressing the need for instituting a set of key
Paediatric Critical Care Research Group, Paediatric Intensive Care Unit, Lady evidence-based interventions to combat this preventable hospital
Cilento Childrens Hospital, Director of Paediatric Critical Care Research Group acquired infection (HAI) [9]. This review explores the issues
(PCCRG), Lady Cilento Childrens Hospital and The University of Queensland, Lady surrounding the denition of VAP including recommendations on
Cilento Childrens Hospital, 501 Stanley St, South Brisbane, Queensland, 4101,
Australia Tel.: +07 3068 8111; fax: +0414869359.
how to address the problem and how to measure success in the
E-mail address: [email protected] (A. Schibler). reduction of VAP in your own institution using strategic guidelines.

http://dx.doi.org/10.1016/j.prrv.2015.09.005
1526-0542/Crown Copyright 2015 Published by Elsevier Ltd. All rights reserved.

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 I. Chang, A. Schibler / Paediatric Respiratory Reviews 20 (2016) 1016 11

PATHOGENESIS OF VAP methods such as blind bronchial sampling (BBS) or protected

specimen brush (PSB) remain controversial [Table 1]. Broncho-
The origin and pathogenesis of VAP remains unclear. Most scopic techniques allow for the direct visualisation of the lower
likely, VAP is the result of micro-aspirations rather than blood airways to aid sampling directly at the site of inammation. The
stream associated inltrates of the lung. Entry of bacteria to the non-bronchoscopic bronchoalveolar lavage (NB-BAL) is performed
lung may be facilitated directly through the endotracheal tube by placing a suction catheter into the endotracheal tube until
(ETT) during disconnection from the ventilator circuit. Most of the resistance is met and then lavaging and suctioning back a small
bacteria found in the endotracheal aspirates of patients suffering amount of sterile normal saline from the lower airway. The
from VAP are also found in the naso-oropharynx and even in gastric bronchoscopic diagnostic methods are not routinely used because
secretions [10]. Therefore, the current literature has emphasised of the technical difculties and complications that could arise such
the role of strategies to prevent VAP. as relative hypoxemia during the procedure despite high inspired
oxygen content leading to a mild increase in PaCO2 and elevation of
VAP DIAGNOSIS intracranial pressure in patients with a closed head injury [17]. On
the other hand, non-bronchoscopic techniques are less invasive
VAP diagnosis has proven to be challenging. Universally and less costly. These blind sampling procedures do less to
accepted criteria are yet to be determined [4]. To date, there is compromise gas exchange during the procedure [13], allowing
only one uniform VAP and surveillance denition which was samples to be obtained successfully from patients with small
published and developed by the US Centres for Disease Control and endotracheal tubes. They can be performed by non-physician
Prevention (CDC), reecting the difculty in making an accurate clinicians [18,19].
and timely diagnosis of VAP [11,12]. There are multiple variables, Compounding factors that contribute to the signicant
including non-invasive and invasive diagnostic strategies, and so variability in incidence of VAP include the use of different gold
each guideline and study needs to be carefully reviewed. The reader standards for diagnosing VAP, the use of different cut off
must consider how the diagnosis of VAP was made, as very different thresholds for quantitative cultures, differences in equipment
outcomes may be reported depending on the denitions used. and protocols, differences in population study and the use of
The most commonly accepted denition of VAP is of a antibiotics. These factors all contribute to the difculty in study
pneumonia occurring after the patient has been intubated and comparison and limited the generalisability of these results [15].
received mechanical ventilation. Although no minimum period has Differences in study methodology and patient characteristics can
been determined before the infection is termed ventilator- also inuence the reported incidences of VAP [20]. Additionally,
associated, it is generally accepted that this should be more than differences in surveillance methods across study institutions also
48 hours [13]. The initial diagnosis is based on clinical suspicion introduce variability into the reported incidence of VAP. Since VAP
and the presence of at least one of the following on two or more is a hospital acquired infection, preventative strategies should be
serial chest radiographs: new or progressive radiographic inl- implemented in bundles and not in isolation of each individual
trates, consolidation, cavitation, and pneumatocoeles in an infant preventive measure.
 1 year old. Additionally, the standard diagnostic criteria include
at least two or three (applicable only for the under 12 year olds) of PREVENTION
the following: fever of > 38 8C or hypothermia of <36.5 8C; change in
sputum volume or character or increased suctioning requirement; Numerous interventions have been studied and shown to
new onset or worsening cough or dyspnoea or tachypnoea or decrease the incidence of VAP in the adult ICU setting [13]. How-
apnoea; rales or bronchial breath sounds or wheezing or rhonchi. ever, little research has investigated the effects of these VAP
A worsening of gas exchange after a period of stability or bundles among ventilated paediatric patients [Table 2].
improvement on the ventilator is used as another criteria (eg, The most common interventions used in the paediatric setting
oxygen desaturations, increased oxygen requirements or increased include hand hygiene, mouth care with antiseptic solution and
ventilator demands), and bradycardia or tachycardia in the 1 year elevating the head of the bed by 30-458. Other interventions used
age group. Serum biomarkers such as C-reactive Protein (CRP) or include changing ventilator circuit only when needing to, drain
procalcitonin (PCT) may also contribute to narrow the diagnostic ventilator condensate away from patient ETT frequently, mini-
margin [14]. The debate to include cultures of endotracheal mising ventilation days by adopting sedation holidays and
secretions remains open. The risk is that a positive result may weaning protocols, ETT cuff pressure maintenance, preference
represent colonization rather than true infection, potentially for orotracheal intubation over nasotracheal intubation, monitor-
leading to inappropriate use of antibiotics. ing of gastric residuals to prevent aspiration and in-line suctioning
The clinical criteria on their own have very limited diagnostic [21,22].
value [15]. Many of the signs and symptoms such as purulent
secretions and increased suctioning requirements are routinely HAND HYGIENE
present in patients receiving prolonged mechanical ventilation or
in those with tracheobronchitis. Chest X-Ray changes can be as a Hand hygiene remains the primary measure to reduce health
result of oedema, atelectasis or haemorrhage. Other signs such as care-associated infection. It is estimated that over 30% of
fever, leucocytosis, apnoea and tachycardia are non-specic which healthcare associated infections are preventable by hand hygiene
can occur in other concurrent morbidities [16]. Moreover, the lack [23]. Its importance warranted international attention, supported
of specic denitions of components of the clinical denitions such by the World Health Organisation (WHO), to highlight the critical
as worsening gas exchange, increased oxygen requirements, and role of hand hygiene in order to control the spread of health care-
increased ventilator settings may contribute to VAP denitions associated infections and multi-resistant pathogens (WHO, 2005).
being applied inconsistently [1]. Similarly, the incorporation of hand hygiene into the VAP bundle
Some clinicians argue that diagnostic criteria should include was recommended and multiple studies have since demonstrated
more invasive methods such as quantitative cultures of lower that hand hygiene adherence is a signicant component of
respiratory tract secretions [11,17]. However, the precise role of strategies to reduce VAP [7,24]. Rello et al. found that hand
diagnostic testing including quantitative cultures in general as hygiene before manipulating airways had more impact on
well as the use of bronchoscopic versus non-bronchoscopic (NB) improving outcomes (VAP rate, ICU length of stay and days of

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Table 1
Numerous studies have demonstrated a signicant degree of variability in sensitivity, specicity, and positive and negative predictive values when it comes to bronchoscopic
diagnostic method. These are presented in the table below:
Turton (2008) [16]) Reviewed 23 studies evaluating the accuracy of  Sensitivity ranged from 42 to 93% with a mean of 73%. Clinical
bronchoscopic BAL in diagnosing VAP. (n= 957 patients). implication is that BAL cultures are not diagnostic for pneumonia in
almost one fourth of cases.
 Specicity ranged from 45 to 100% with a mean of 82%. This means
that the diagnosis is incorrect in about 20% of cases.

Chastre & Fagon (2002) [10] Reviewed 18 studies that evaluated the bronchoscopically Sensitivity 89%
directed PSB technique for diagnosing VAP. A total of Specicity 94%
795 critically ill patients were included in the analysis.

Chastre et al., (1995) [10] Compared PSB and BAL to the gold standard of histologic  PSB had a sensitivity of 82%, specicity of 77%, positive predictive
ndings and quantitative tissue cultures from the same value of 74%, and negative predictive value of 85%.
areas of the lungs of patients in their terminal phase of their  BAL had a sensitivity of 91%, specicity of 78%, positive predictive
illness (who had not developed pneumonia before the value of 83%, and negative predictive value of 87%.
terminal phase of their illness). 20 ventilated patients were  Quantitative tissue cultures: the presence of  5% intracellular
included in this study. organisms had a sensitivity of 91%, specicity of 89%, positive
Antibiotics had not been added or changed in the 3 days predictive value of 91%, and negative predictive value of 89%.
prior to sampling.
Gauvin et al., (2003) [58] Expert panel was used as the reference standard. They were  Intracellular bacteria and gram stain from BAL were specic (95%
given clinical, radiographic and microbiologic data but were and 81% respectively) but not sensitive (30% and 50% respectively)
blinded to the BAL results. Of 30 patients, 10 were for the diagnosis of paediatric VAP.
diagnosed with VAP and 9 were diagnosed with ventilator-  Clinical criteria and endotracheal cultures were sensitive (100%
associated tracheitis by an expert panel. and 90% respectively) but not specic (15% and 40% respectively).
 A bacterial index of > 5 had the highest correlation with the
reference standard. A sensitivity of 78%, specicity of 86%, a positive
predictive value of 70% and a negative predictive value of 90%. This
is the most reliable method for diagnosing VAP in mechanically
ventilated children.

Labenne et la., (1999) [59] Investigated the sensitivity and specicity of PSB and BAL in  The sensitivity and specicity for BAL uid culture were 72% and
PICU patients with suspected VAP. The gold standards used 88% respectively.
by those investigators were a positive pleural uid culture,  The intracellular bacteria and BAL combined had sensitivity and
computed tomography scan with pulmonary abscesses, specicity of 79% and 88% respectively.
histopathological evidence, positive lung biopsy (> 104  Use of PSB culture results in combination with intracellular
CFU/gram), the same bacteria isolated in blood and bacteria and BAL further increased the sensitivity and specicity to
endotracheal aspirate without another source, or clinical 90% and 88% respectively.
diagnosis using CDC guidelines established independently  Their conclusion was a combined diagnostic approach was
by two investigators blinded to PSB/BAL culture results. Of superior to either one alone.
103 patients, 29 were diagnosed with VAP.

mechanical ventilation) than other variables [7]. Similarly, Koff CUFFED ENDOTRACHEAL TUBES AND CUFF PRESSURE CHECKS
et al. instituted a novel multimodal system designed to improve
hand hygiene by ICU providers [24]. They found an increased The use of cuffed ETTs could potentially decrease risk of
compliance to hand hygiene resulted in a signicant reduction of aspiration, reduce the need to change ill-tting tracheal tubes,
VAP incidence. There is no doubt that hand hygiene compliance is alter fresh gas ow consumption resulting from excessive leak and
imperative, but the compliance rate amongst attending healthcare lower the usage of over-sized uncuffed tubes, the main cause of
professionals remains low. Therefore, strict hand hygiene guide- subglottic stenosis [27]. In another study comparing cuffed to
lines need to be reinforced in the clinical setting. uncuffed ETTs, a total of 2246 children from birth to 5 years who
weighed at least 3 kg from 24 European paediatric anaesthesia
ROUTE OF ENDOTRACHEAL INTUBATION centres were studied [28]. It was found that post extubation stridor
rates were similar in both groups [28]. Tracheal tube exchange rate
In a retrospective chart review, the occurrence of sinusitis in a was considerably lower in the cuffed tube group with only 2.1%
paediatric population was recently investigated [25]. Out of a total compared to 30.8% in the uncuffed groups. Considering micro-
of 596 ventilated children having computer tomography (CT) aspiration of contaminated oral secretions is one of the mechanisms
imaging of the head, 44.3% had radiological evidence of sinusitis leading to VAP, the use of cuffed ETTs may be benecial in VAP
without clinical sinus disease. However, no signicant difference prevention as the superior tracheal seal may decrease the incidence
was found in the frequency of sinusitis when comparing oral and of micro-aspiration. A larger randomised trial is desirable to conrm
nasal tubes. In addition, Amantea et al. (2004) performed a study this nding. In the interim it would seem reasonable to use a cuffed
on 50 spontaneously breathing, mechanically ventilated, supine ETT with regular cuff pressure monitoring.
children with uncuffed endotracheal tubes (ETT) [26]. Potential
aspiration was assessed by instilling 1 ml of Evans blue dye FREQUENCY OF VENTILATOR CIRCUIT CHANGES
into the oropharynx and then evaluating the ETT secretions.
They found that children with orotracheal tubes had a higher Several RCTs were conducted to investigate the frequency of
prevalence of aspiration compared with nasotracheally intubated changes to humidied circuitry. This included 2-day versus 7-day
children (37.1% vs. 6.7%) and recommended the use of the intervals [29], 3 day versus 7 day intervals [30]), 7-day versus no
nasotracheal route for intubation. This recommendation however change [31] and a prospective study of 2 day versus 7-day and
is in contrast with a previous prevention strategy suggested by 30 day intervals [32]. All these studies supported the hypothesis
Muscedere et al. [21,22]. that there was no increased incidence of VAP when the frequency

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Table 2
What key interventions have been used for paediatric VAP bundle?

Reference VAP bundle implemented Outcomes

Brierley, et al. (2012) [60]  Head up tilt (target 458, but achieved 20-308) Pre- bundle VAP is 5.6/1000 ventilator days.
 Mouth care with oral antiseptic every 4 hourly OR 12 hourly toothbrush Post bundle VAP is 0/1000 ventilator days over
 Clean suctioning practice 12 month period.
 Gastric ulcer prophylaxis: Ranitidine
 Chest X-Ray interpretation (Physio to complete)
 Documentation to be completed 4 hourly
 Indication of VAP compliance to be documented each shift
Bigham, et al. (2009) [61] Prevention of bacterial colonisation of oropharynx, stomach & sinuses The VAP rate was reduced from 5.6 to
 Change ventilator circuits and in-line suction catheters only when visibly 0.3 infections per 1000 ventilator days after
soiled bundle implementation
 Drain condensate from ventilator circuit at least every 2-4 hours (use heated
wire circuits to reduce rainout)
 Store oral suction devices (when not in use) in non-sealed plastic bag at the
bedside; rinse after use
 Hand hygiene before and after contact with ventilator circuit
 When soiling from respiratory secretions is anticipated, wear gown before
providing care to patient
 Follow unit mouth care policy every 2-4 hours

Prevention of aspiration of contaminated secretions

 Elevate HOB 30-458, unless contraindicated and by written order
 Always drain ventilator circuit before repositioning patient
 When possible, for children > 12 years old, use endotracheal tube with dorsal
lumen above endotracheal cuff to help suction secretions above the cuff
Rosenthal, et al. (2012) [8]  Adherence to hand hygiene guidelines VAP rate was 11.7/1000 ventilator days during
 Semi-recumbent position 30-458 baseline period and 8.1/1000 ventilator days
Countries involved include:  Daily assessment to wean and use of weaning protocols during the intervention period (31% reduction
Colombia  Use of non-invasive ventilation whenever possible, minimising the duration of in VAP rate).
India ventilation
Philippines  Preference of orotracheal intubation over nasotracheal intubation
El Salvador  Maintenance of endotracheal cuff pressure of at least 20 cm H2O
Turkey  Removal of condensate from ventilator circuits, keeping the ventilator closed
during condensate removal
 Changing of the ventilator circuit only when visibly soiled or malfunctioning
 Avoidance of gastric over distension
 Avoidance of histamine-receptor 2-blocking agents and proton pump
inhibitors
 Use of sterile water to rinse reusable respiratory equipment

of ventilator circuit changes was reduced. Cost considerations The use of normal saline instillation (NSI) prior to endotracheal
clearly favour less frequent changes. suctioning has been practised widely in intensive care units to
assist with eliciting cough, and the dilution and removal of thick
SUCTIONING TECHNIQUES AND EQUIPMENT secretions. It has been argued that NSI could increase the incidence
of VAP because it dislodges more viable bacterial colonies from the
Maintenance of aseptic techniques when performing endotra- endotracheal tube to the lower respiratory tract than the insertion
cheal suctioning is essential to prevent contamination of the of a suctioning catheter without saline instillation. Interestingly,
airways [33]. There are very few studies that have addressed Caruso et al. (2009) found a decrease in the incidence of culture
suctioning techniques and the prevention of infection. A system- proven VAP with the instillation of isotonic saline before tracheal
atic review of suctioning in adults with an articial airway suctioning in their randomised clinical trial of 262 patients
recommended an aseptic technique be maintained throughout the utilising a closed suctioning system [38].
whole procedure [34]. The importance of an aseptic technique is
further highlighted by a study performed by Sole et al. (2002) to SEMI-RECUMBENT POSITIONING
evaluate the proportion of suctioning devices colonised with
pathogenic bacteria and to correlate the bacteria found on Positioning of intubated patients is believed to be a signicant
respiratory equipment with those found in patients mouth and element in VAP prevention. The 30-458 semi-recumbent or head of
sputum [35]. Those investigators found that within 24 hours of bed elevation has been widely recommended in the literature [39]
changing to new suctioning equipment, 94% of tonsil suction and endorsed by the US Centres for Disease and Prevention (CDC)
tubing, 83% of in-line suction tubing and 61% of distal suction as one of the most simple and effective strategy in VAP prevention
connectors were colonised with pathogenic bacteria similar to [11]. A clinical randomised cross over trial demonstrated greater
those found in the patients oropharynx and sputum. aspiration of gastric contents to the airways when patients were
Several studies have been conducted comparing open versus kept in the supine position despite ination of the endotracheal tube
closed suction systems and VAP incidence. A closed suction system cuff [40]. Additionally, the length of time spent in this position was
was introduced to address some of the complications associated proportionate to an increased aspirated content. The semi-recum-
with the traditional open system suctioning procedure, including bent position of patients has been effective in preventing aspiration
environmental contamination, cross infection, hypoxia and alveo- of the gastric contents [41]. A few years later, another randomised
lar de-recruitment. Multiple trials have found no difference in VAP trial demonstrated that semi-recumbent position is more effective
incidence utilising either suctioning system [36,37]. in reducing VAP incidence than the supine position [42].

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However, recently some investigators have questioned whether Oral decontamination with chlorhexidine (CHX) has also been
this position is optimal for VAP prevention [43]. Panigada et al. suggested to decrease the incidence of VAP in studies [55]. CHX
argued that in the semi-recumbent position, gravitational forces has the ability to maintain oral health by suppressing overgrowth
will facilitate contaminated subglottic secretions travelling across of gram-positive and gram-negative bacteria as well as yeast,
the tracheal cuff, entering the lower respiratory tract especially without causing increased resistance of oral bacteria. Subse-
during suctioning because of the pressure drop within the quently, it is often used to reduce dental plaque as well as
respiratory system [44]. At the same time, lower respiratory tract preventing gum disease such as gingivitis. Hence, the risks of
secretions cannot be cleared out of the trachea, except during exposing the lungs to pathogenic bacteria can be reduced when
suctioning. This claim was supported by an animal study which micro-aspiration of oral secretions occur around the endotra-
showed that gravitational forces inuenced tracheal mucus cheal tube.
clearance following tracheal intubation [45]. When the trachea
is oriented above horizontal (as in the semi-recumbent position in
the human), a ow of mucus from the proximal trachea toward the
lungs is highly associated with bacterial colonisation of the lungs
Recommendations to reduce the risk of VAP:
and pneumonia. Whereas, when the trachea is oriented even
slightly below horizontal, mucus always moved toward the glottis
and lungs remained free from bacterial colonisation [43]. In  Strict hand hygiene guideline is to be employed in the
another study, comparing patients placed in the lateral horizontal clinical setting.
position compared to patients in semi-recumbent position, it was  Orotracheal vs. nasotracheal intubation route in paediat-
demonstrated that the incidence of aspiration of gastric contents ric population requires further study before recommen-
was similar in both positions [46]. In addition, the lateral position dation can be made in respect to VAP prevention.
did not cause any adverse events. Currently, a multinational trial is  Ventilator circuit change is only warranted if the circuit
undergoing to corroborate the benet of lateral Trendelenburg become visibly soiled or malfunctions.
versus semi recumbent body position in intubated patients with  Adopt aseptic technique when performing endotracheal
relation to the incidence of VAP.
tube suctioning. Suctioning equipment may benet from
changing every 24 hour. Rinse out Yankeur sucker and
ORAL HYGIENE
suction tubing with water after each use.
Poor oral hygiene has been identied as having a strong  Comprehensive oral hygiene program incorporating
association with VAP [47,48]. Bacterial plaque can build on teeth chlorhexidine use, tooth brushing and sterile water are
within 72 hours after cessation of an adequate oral hygiene regime. to be adopted for all mechanically intubated children.
In addition, the formation of an oral biolm on the non-shedding
surfaces of teeth serves as a susceptible medium for colonization
by respiratory pathogens [47,49]. Many of these pathogenic
bacteria can migrate into the lung directly via the open route TREATMENT
provided by the presence of an endotracheal tube (ETT) which
increases the risk of VAP. Once VAP has been diagnosed, timely antibiotic treatment
A comprehensive oral hygiene program in acute care settings is should be initiated. A number of studies have demonstrated
essential to prevent VAP and has been recommended by the CDC that delays in the administration of effective treatment are
[11]. In a systematic review of oral assessment instruments, out of associated with increased morbidity, costs of care and mortality
fty-four different instruments only four were identied for use in [56]. There are commonly multiple organisms involved in VAP
children and young people [50]. The review identied the Oral and during early onset VAP; bacteria such as Staphylococcus
Assessment Guide [OAG] developed by Eilers et al. (1998) for use in Aureus, Streptococcus pneumoniae and Haemophilus inuenzae are
the care of children and young people with cancer to be the most frequently cultured [23]. Enteric gram-negative bacilli are
appropriate and clinically useful instrument for optimising oral occasionally observed. In late onset VAP more nosocomial
hygiene in the intensive care setting [51]. Excellent inter-rater bacteria are found that are often multi-resistant to antibiotics.
agreement between clinical nurses was demonstrated and it was These include Pseudomonas aeruginosa, Acinobacter sp, Stenotro-
preferred over other instruments. The OAG was also found to be phomonas maltophilia and enteric gram-negative bacilli
clinically useful for assessment, documentation and communica- including Enterobacter sp., Klebsiella sp. and Citrobacter sp. Each
tion on oral changes, effective in detecting changes in oral status hospital and paediatric intensive care unit needs collaboration
and useful in guiding nursing interventions. with infection control (IC) guidelines in the treatment of VAP to
Traditionally, foam swabs dipped in tap water or mouthwash contain the spread of multi-resistant bacteria. The duration of
had been used extensively in critical care settings to provide oral antibiotic treatment remains controversial but it seems that a
care for those who are receiving mechanical ventilation [52]. There shorter duration of administration is sufcient [57]. A short and
has been substantial research dedicated to comparing the efcacy pragmatic approach is given in Figure 1.
of foam swabs with a toothbrush in their ability to remove dental
plaque and debris to maintain oral health. Foam swabs were less
effective in comparison to tooth brushing in plaque removal SUMMARY
[53]. The use of a small, soft toothbrush is the recommended tool in
most literature for providing oral hygiene for mechanically There is no gold standard for diagnosing VAP, in either the adult
ventilated patients [47]. Tap water is used in many critical care or paediatric intensive care setting, but it is accepted that VAP
units for providing oral care. Researchers had noted that contributes to a signicant increase in health care costs. The
potentially pathogenic bacteria were present in the water supply emphasis in each individual unit should be to prevent VAP using
of health care facilities and stated that tap water should not be simple measures as high hand hygiene standards. Early antibiotic
used as a mouth rinse for critically ill patients since it can be a treatment seems to be the key for successful treatment and
source of nosocomial infections [54]. reduction of associated co-morbidities.

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