Ventilator-Associated Pneumonia: Insights From Recent Clinical Trials

Andrew F. Shorr and Marin H. Kollef

Chest 2005;128;583-591
DOI: 10.1378/chest.128.5_suppl_2.583S

This information is current as of January 5, 2006

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Ventilator-Associated Pneumonia*
Insights From Recent Clinical Trials
Andrew F. Shorr, MD, MPH, FCCP; and Marin H. Kollef, MD

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the ICU and
contributes disproportionately to both poor outcomes and the high cost of care in critically ill
patients. While VAP has been the focus of extensive research, little consensus exists about
methods for diagnosis, treatment, or prevention. Delays in initiating appropriate therapy,
antibiotic resistance due to indiscriminate and prolonged use of broad-spectrum antibiotics, and
treatment of patients with a low risk of VAP (based on clinical pulmonary infection scores)
represent a sample of VAP-related issues that have been addressed in recent clinical trials.
Educational programs for VAP prevention and other nonpharmacologic strategies aimed at
eliminating VAP have also been explored in clinical investigations. This review highlights selected
areas of new clinical research on VAP treatment and prevention in order to place their
significance in context. (CHEST 2005; 128:583S–591S)

Key words: antibiotic resistance; antibiotic therapy; ventilator-associated pneumonia

Abbreviations: CPIS ⫽ clinical pulmonary infection score; MRSA ⫽ methicillin-resistant Staphylococcus aureus;
NIV ⫽ noninvasive mechanical ventilation; VAP ⫽ ventilator-associated pneumonia

Learning Objectives: 1. To provide an update on the incidence of and potential consequences associated with
ventilator-associated pneumonia. 2. To review current research on the topic of ventilator-associated pneumonia,
including strategies for its treatment and prevention in critically ill patients.

V entilator-associated pneumonia (VAP) remains

an area of active clinical investigation. Despite an
comial infections in US ICUs are pneumonia4; of
these, 83% are associated with mechanical ventila-
improved understanding of this disease, multiple tion. Financially, several estimates suggest that the
controversies remain about strategies for diagnosis, attributable costs of VAP approach $12,000 per
prevention, and management. There is, however, case.5 The impact of VAP is also felt by society.
general agreement about the burden of VAP and its Patients acquiring VAP have poorer outcomes,
high cost.1–3 According to the National Nosocomial longer lengths of hospital and ICU stay,3 and higher
Infection Surveillance system, one third of all noso- mortality rates.1,5,6
Changes in pathogen distribution and patterns of
antibiotic resistance have complicated care.7 Specif-
*From the Pulmonary Clinic (Dr. Shorr), Pulmonary and Critical
Care Medicine Service Department of Medicine, Walter Reed ically, increased use of all classes of antibiotics over
Army Medical Center, Washington, DC; and Pulmonary and the past 10 years has correlated with alarming de-
Critical Care Division (Dr. Kollef), Washington University clines in susceptibilities. This has simultaneously
School of Medicine, Barnes-Jewish Hospital, St. Louis, MO.
The honorarium for this article has been donated to the Army heightened the need to adopt multidrug regimens
Emergency Relief Fund. for the initial treatment of nosocomial infections.7 In
The following authors have disclosed financial relationships with turn, this creates additional selection pressure and,
a commercial party. Grant information and company names
appear as provided by the author: Andrew F. Shorr, MD, FCCP: concomitantly, more resistance.
Ortho Biotech - Consultant fee. Several investigators8,9 have identified the initial
The following authors have indicated to the ACCP that no antibiotic regimen as a key determinant of patient
significant relationships exist with any company/organization
whose products or services may be discussed in their article: outcome, and local microbiologic patterns are critical
Marin H. Kollef, MD, FCCP. to guide the choice of a suitable initial treatment
This publication was supported by an educational grant from regimen. Observational studies10,11 suggest that cli-
Ortho Biotech Products, L.P.
Reproduction of this article is prohibited without written permission nicians’ primary antibiotic selections for VAP are
from the American College of Chest Physicians (www.chestjournal. inadequate (eg, the antibiotic administered does not
org/misc/reprints.shtml). cover the pathogen or the pathogen is resistant to
Correspondence to: Andrew F. Shorr, MD, MPH, FCCP, Pulmo-
nary and Critical Care Medicine, Washington Hospital Center, that antibiotic) in over one third of cases. The price
Washington, DC; e-mail: [email protected] of making an incorrect anti-infective decision is high.

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As with other infections encountered in the ICU, resistance of Pseudomonas aeruginosa to ciprofloxa-
delayed treatment with appropriate antibiotics inde- cin has risen from 17 to 32% between 1994 and 2000
pendently increases the risk for death from VAP.11 In and has doubled for other Gram-negative bacilli as
an effort to improve outcomes, trials have examined well.7 This trend was coincident with a 2.5-fold
mechanisms for ensuring adequate antimicrobial increase in fluoroquinolone utilization nationally
coverage. One approach, the creation of VAP man- (Fig 1). Moreover, Neuhauser and colleagues7 ob-
agement guidelines, has proven highly successful.12 served cross-resistance to cephalosporins and amino-
Because of costs and the concern about overuse and glycosides with selected strains of bacteria, including
abuse of antibiotics, nonpharmacologic strategies for P aeruginosa, Enterobacter species, and Klebsiella
the prevention of VAP have also attracted consider- pneumoniae. They and others17 have hypothesized
able attention. Health-care worker hygiene (eg, hand that this has transpired because of the tendency for
washing), patient positioning techniques, ventilator fluoroquinolones to select for bacteria with increased
device care, and noninvasive ventilation are some efflux capacity for antibiotics. Although Gram-nega-
examples of these strategies.13 Although prevention tive pathogens have been implicated in ⬎ 60% of
can play a key role in reducing VAP incidence, these VAP cases, Gram-positive pathogens are increasingly
methods may require significant educational com- prevalent in the ICU.1 The incidence of VAP due to
mitments and high rates of compliance in order to Staphylococcus aureus now rivals that caused by P
achieve success.14 aeruginosa. Additionally, methicillin-resistant S au-
Whether attempting to treat or prevent this costly reus (MRSA) presently account for 50 to 70% of S
complication of ICU care, intensivists are constantly aureus encountered in the ICU. This fact further
challenged to evaluate results from clinical trials and complicates antibiotic prescribing since broader use
to keep abreast of current issues and trends in the of vancomycin, as the prevalence of MRSA dictates,
management of VAP. The purpose of this manu- creates selection pressure for the development of
script is, therefore, to review key findings from vancomycin-resistant enterococci.
selected recent studies regarding VAP treatment and
prevention.
Duration of Therapy
The duration of antibiotic therapy for VAP pre-
Treatment Issues in VAP sents another conundrum. Until recently, antibiotic
treatment durations were based on expert opinion
Antibiotic Use and Rising Resistance
rather than randomized trials. Selecting a treatment
Few topics in intensive care medicine are as duration requires one to balance the risk of either
heavily discussed and debated as antibiotic use. Prior failure or relapse with short treatment courses
antibiotic exposure together with duration of me- against the threat of antibiotic overuse with more
chanical ventilation represent important risk factors extended regimens.18 The belief that longer antibi-
for development of VAP with resistant organisms.15 otic regimens pose no risk to the patient as long as
Antibiotic selection has the potential to influence the the specific agents used are effective against the
spectrum of bacteria endogenous to the hospital and infecting organisms is false. For example, despite
community,13 and health-care providers need to initial resolution of clinical parameters of infection
appreciate that their antibiotic choices have down- within 6 days of instituting appropriate antibiotic
stream consequences. Although prompt identifica- therapy, Dennesen and co-workers19 noted that
tion of infection and isolation of the infecting organ- Gram-negative pathogens reemerged to colonize the
ism can pose considerable challenges in the ICU, trachea during the second week of therapy. This led
choosing the appropriate antibiotic that will treat the to recurrence of VAP but now with strains that were
culprit pathogen and that simultaneously possesses resistant to the original anti-infectives employed.19
the narrowest spectrum of activity can be equally To discourage such colonization pressure, shorter
challenging. A recent review of appropriate antibac- 7-day courses of antibiotic therapy have been pro-
terial utilization with examples of successful de- posed for VAP.19 In a randomized 51-center trial,
escalation approaches underscores the importance of Chastre and colleagues18 tested the hypothesis that
these strategies to contain costs, reduce morbidity, short courses (8 days) of initially appropriate antibi-
and control the spread of resistance.16 otic therapy for VAP are as effective as traditional
Prolonged and indiscriminate use of antibiotics courses (15 days). The study18 included 401 patients
has affected antibiotic resistance patterns and the and was double blinded in the initial phase, through
sensitivities of organisms frequently encountered in day 8. Antibiotic selections were not protocolized
the ICU. Recent susceptibility data for Gram-nega- and were made at the physician’s discretion based on
tive isolates from ICUs in 43 states show that cultures obtained following bronchoscopy (day 1).

584S Improving Outcomes in Respiratory Failure: Ventilation, Blood Use, and Anemia Management
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 Figure 1. Impact of fluoroquinolone use on resistance of P aeruginosa and Gram-negative bacilli.7 The
increasing rates of ciprofloxacin resistance correlate with the steadily increasing fluoroquinolone use
(r ⫽ 0.976, p ⬍ 0.001 for P aeruginosa; r ⫽ 0.891, p ⫽ 0.007 for Gram-negative bacilli; r ⫽ 0.958,
p ⬍ 0.001 for years of observation). The data points from 1990 to 1993 represent composite
susceptibility and fluoroquinolone use for those 4 years. Data used with permission from Neuhauser et
al.7

Empiric therapy was initiated on day 1, incorporated ing Gram-negative bacilli, the authors18 determined
local antibiogram information, and continued until that longer courses of treatment offer no clinical
susceptibility results were obtained (48 to 72 h after advantage. Readers should note that a crucial aspect
bronchoscopy). At that point, investigators random- of the trial design required patients to be receiving
ized patients to receive either the 8- or 15-day appropriate antibiotics, based on the results of cul-
therapies. The primary outcome measures, assessed tures obtained from bronchoscopy, in order to con-
at day 28, were death from any cause, antibiotic-free tinue in the study after initial evaluation. If subse-
days, and recurrence of documented pulmonary quent invasive testing revealed that a patient had
infection. There were no differences in the rate of been treated with antibiotics that were not active
death or in the incidence of pulmonary infection against the responsible pathogen, the patient was
between the two groups. More importantly, patients excluded from further participation. If clinicians
randomized to the 8-day cohort had significantly
wish to shorten the length of therapy for VAP,
more antibiotic-free days (13.1 ⫾ 7.4) than those in
therefore, they must ensure that their original anti-
the 15-day cohort (8.7 ⫾ 5.2 [mean ⫾ SD];
biotic choices are correct. In other words, in order
p ⬍ 0.001). Overall, among those with recurrences
of pulmonary infections (28.9% in the 8-day cohort for the VAP treatment paradigm to shift from longer
vs 26.0% in the 15-day cohort), fewer resistant to shorter durations, it is imperative that the antibi-
strains were detected in patients assigned to the otic regimen chosen provides adequate coverage
short course. Secondary outcomes measures, includ- from the start and is initiated promptly.
ing the number of mechanical ventilation-free days,
organ failure-free days, physiologic parameters, and Appropriate and Prompt Prescribing
ICU length of stay, were similar. Thus, the authors18
concluded that the shorter regimen was not inferior Intensivists should not underestimate the fre-
to the longer regimen. Pulmonary infections due to quency at which the antibiotics they choose are
nonfermenting Gram-negative bacilli recurred more inappropriate or are not given in a timely manner.
frequently with the 8-day course, although in this For example, Iregui et al11 reported that delays in
subpopulation mortality and outcomes were similar therapy of at least 24 h occur in almost one third of
regardless of the duration of antibiotic therapy. With VAP cases after diagnosis, with the writing of anti-
the possible exception of immunocompromised pa- biotic orders being the most common cause of delay.
tients and persons with infections from nonferment- Furthermore, the consequence of inappropriate an-

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tibiotic prescribing was significant in this study in Table 1—CPIS Calculation*
that it independently increased the risk for death Parameters Points
nearly sevenfold.
One strategy for improving appropriate and timely Temperature, °C
ⱖ 36.5 and ⱕ 38.4 0
prescribing of anti-infectives for VAP is to adopt ⱖ 38.5 and ⱕ 38.9 1
clinical guidelines to assist in antibiotic management ⱖ 39.0 and ⱕ 36.0 2
decisions. Before and after implementation of a VAP Blood leukocytes, ␮L
treatment guideline in one ICU, Ibrahim and col- ⱖ 4,000 and ⱕ 11,000 0
leagues20 demonstrated that initial administration of ⬍ 4,000 or ⬎ 11,000 (with band forms ⬎ 50%) 1 (⫹1)
Tracheal secretions
appropriate therapy increased from 48.0 to 94.2% None 0
(p ⬍ 0.001). The achievement of high rates of ini- Nonpurulent secretions present 1
tially appropriate coverage necessitated that their Purulent secretions present 2
guideline suggest starting with a broad-spectrum Oxygenation: Pao2/fraction of inspired oxygen, mm Hg
multidrug combination. Specifically, it included cov- ⬎ 240 or ARDS† 0
ⱕ 240 and no ARDS 2
erage not only for resistant Gram-negative pathogens Pulmonary radiography
but also for MRSA. Although this approach might No infiltrate 0
raise concern about contributing further to selection Diffuse or patchy infiltrate 1
pressure for resistance, Ibrahim et al20 concomitantly Localized infiltrate 2
hypothesized that by guaranteeing correct coverage Progression of pulmonary infiltrate
No radiographic evidence of progression 0
initially they would be able to shorten the duration of Radiographic progression (congestive heart failure and 2
therapy. In fact, as a tradeoff for using multiple ARDS excluded)
agents at the outset, they curtailed therapy at 8 days Pathogenic bacteria cultured from tracheal aspirate
if the patient was improving clinically. With imple- Rare or light quantity or no growth 0
mentation of their practice guideline they found that Moderate or heavy quantity (with same growth on 1 (⫹1)
Gram stain)
actual treatment durations decreased from
14.8 ⫾ 8.1 days to 8.6 ⫾ 5.1 days (p ⬍ 0.001). This *Data are used with permission from Pugin et al22 as adapted by
Singh etal.21
was also associated with a simultaneous reduction in
†Defined as Pao2/fraction of inspired oxygen ⱕ 200, pulmonary
VAP recurrence from 24.0 to 7.7% (p ⫽ 0.03). arterial wedge pressure ⱕ 18 mm Hg, and acute bilateral infiltrates
Pressure on physicians to ensure initially appropri-
ate antibiotic therapy leads them to quickly initiate
therapy even in patients with a low likelihood of
infection. Again, one can see the cost of this type of tively serve as a tool to limit antibiotic abuse. The
practice in the rising rates of resistance in the ICU. authors22 were cautious to point out the limitations
Singh et al21 explored if it were possible to “wean” of their pilot, unblinded, single-center study. They
intensivists from the overuse of antibiotics and to recommended that each institution undertake its
guide them to be better antibiotic stewards. Using a own assessment of antibiotic utilization practices
modified version of the clinical pulmonary infection before implementing ultrashort empiric therapy.
score (CPIS) [Table 1] proposed by Pugin and Nevertheless, these researchers provide a provoca-
colleagues22 to objectively stratify patients by likeli- tive solution for reducing antibiotic use in the setting
hood of pneumonia, Singh and coworkers21 random- of suspected VAP. Taken as a whole, the results from
ized subjects less likely to have an infection (CPIS all of these trials demonstrate that the responsibility
ⱕ 6) to either standard care (10 to 21 days, at the for improvement rests with clinicians. Controlling
discretion of the health-care provider) or to a short the duration of therapy to limit the spread of resis-
course of empiric therapy (ciprofloxacin for 3 days tance is indeed possible, if and when therapy is
followed by reevaluation, with discontinuation of appropriate, initiated promptly, and administered to
treatment if the CPIS remained ⱕ 6). Outcomes for the appropriate patients.
patients treated with the short course were compa-
rable to those receiving standard therapy. Thus, in
patients with an initial CPIS ⱕ 6, longer antibiotic Prevention Strategies for VAP
regimens of 10 to 21 days may not be necessary. It is
important to note that given the low CPIS coupled Given cost-containment pressure and shrinking
with the rapid improvement in the patients studied, health-care resources, efforts aimed at preventing
it is likely that few actually had pneumonia. Addi- VAP are of paramount importance. For the reasons
tionally, the trial should not be viewed as an inves- discussed above, namely, the emergence of multire-
tigation of the diagnostic value of the CPIS. Rather, sistant bacteria, strategies employing prophylactic
these researchers explored if the CPIS could effec- antibiotics such as selective decontamination of the

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GI tract are controversial and not widely accepted in ers found that concerns about patients sliding in the
the United States.23,24 Fortunately, multiple less bed,27 having reduced lateral movement, and patient
controversial nonpharmacologic strategies for VAP discomfort were the most common reasons offered
prevention exist. Most are well known25 but have not for noncompliance. Although Helman et al27 were
received the attention they merit. encouraged that head-of-bed angles increased an
average of 11° over baseline, they emphasized that
Semirecumbency such interventions, simple as they may seem, require
intense education, constant follow-up, and behavior
One of the simplest and least expensive measures modification on the part of physician, nursing, and
is maintaining the patient’s head of bed in an respiratory therapy staff. Further research is needed
elevated position. Increasing the head-of-bed angle to define whether head-of-bed positioning at ⱖ 30°
is effective because it decreases the risk of aspiration or ⱖ 45° prevents VAP to a different extent, since
of both gastric contents and of secretions from the lower angles were easier to achieve.
upper aerodigestive tract. These secretions are often
colonized with potentially pathogenic bacteria, and
Educational Initiatives and Guidelines
generally colonization precedes infection. In a ran-
domized prospective study conducted by Drakulovic The power of educational initiatives and their
and colleagues26 in patients receiving mechanical potential to lead to significant reductions in VAP is
ventilation, semirecumbent positioning to ⱖ 45° sig- striking. Zack and coworkers14 described the impact
nificantly reduced the risk of clinically suspected of a self-study instructional module on VAP preven-
pneumonia by ⬎ 25% compared to the supine posi- tion strategies. A multidisciplinary task force com-
tion. Although a well-recognized, simple, and inex- prised of two physician leaders and members of the
pensive intervention, Helman et al27 noted during hospital infection control team developed the pro-
informal observation that the majority of patients gram. Their educational module targeted respiratory
receiving mechanical ventilation in their ICU had care practitioners and critical care nurses. The in-
head-of-bed angles maintained at ⬍ 30°, consistent tense but simple educational effort, involving before
with the findings of others.27–29 These authors at- and after testing, facilitated the reduction of VAP by
tempted to change behavior and practice in their 57.6%. ICUs with the highest initial rates of VAP
ICU by creating a standardized order set that re- accounted for the largest decreases in VAP incidence
quired head-of-bed positioning at a ⱖ 45° angle. (Fig 2). The authors14 estimated that their project
With this tactic, investigators enhanced compliance, yielded significant cost savings: up to $4 million
which climbed from 3% before intervention to 16% annually. The success of the initiative was, in part,
(p ⬍ 0.05). Supplemented with educational pro- attributed to the participation of physician leaders
grams, head-of-bed positioning compliance further and hospital administrators, as well as the general
improved. In interviews with nurses, these research- acceptance of the common goal, preventing VAP.

Figure 2. Impact of educational efforts on reduction of VAP rates in individual ICUs. Data are from
Zack et al14 *Significant decrease in VAP rates before and after intervention (p ⬍ 0.001).

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 Not all guidelines or educational initiatives have dications (eg, hemodynamic instability), risk of harm
achieved such success. Scarcity of resources, patient (eg, decubitus ulcers), safety (eg, sliding out of the
discomfort, disagreement with trial results, fear of bed), and available resources (eg, insufficient beds
potential adverse effects, and costs may impede facilitating semirecumbency). When made aware of
adoption of comprehensive preventive strategies.30 the evidence, all participants endorsed the use of
In a survey conducted by Ricart and colleagues,30 semirecumbency. Armed with this information, clin-
nurses tended to cite patient discomfort and safety ical guidelines and educational programs can be
issues, whereas physicians were more likely to name better designed to address these issues in an effort to
costs or differences in interpretation of clinical trial improve compliance.
results as reasons for nonadherence with evidence-
based preventive strategies. Compliance with pre-
Noninvasive Ventilation
vention recommendations also appears to vary be-
tween countries. Cook et al31 compared Canadian Several other nonpharmacologic strategies aimed
and French ICUs regarding the use of seven strate- at VAP prevention have been the subject of research.
gies to control secretions and care for ventilator Noninvasive mechanical ventilation (NIV) has been
circuits to prevent VAP and reduce overall health- shown to reduce the incidence of VAP and mortality
care costs. Adherence to specific prevention guide- in clinical trials of selected populations.33 By avoid-
lines for VAP was statistically more common among ing endotracheal intubation, NIV removes a major
French ICUs (64% vs 30%, p ⫽ 0.002), although risk factor for the development of VAP. However,
rates were low in both countries. These investigators broader reliance on NIV has been limited. Girou and
also found that published recommendations did not colleagues34 have documented the value of NIV.
appear to substantially affect whether prevention Over the course of an 8-year longitudinal study in
interventions were used within individual ICUs. patients with acute exacerbations of COPD or severe
Cook et al32 also surveyed clinicians to determine cardiogenic pulmonary edema, they observed that
specifically the reasons for the lack of use of semi- increased utilization of NIV was associated with
recumbency to prevent hospital-acquired pneumo- decreased VAP rates and lower mortality (Fig 3).
nia/VAP. Nurses perceived that the main determi- The relationships between NIV and improved sur-
nant of semirecumbency was physicians’ orders, vival remained statistically significant after adjusting
whereas intensivists perceived that the main deter- for multiple potential confounding variables includ-
minant was nurses’ preferences. Participants identi- ing severity of illness, bronchodilator use, and pro-
fied barriers to semirecumbency related to useful pensity scores (eg, probability of receiving treatment
alternative positions (eg, lateral position), contrain- with NIV over the years). In their multivariate

Figure 3. Trends in NIV and associated outcomes34: time-trend analysis of NIV use (p ⬍ 0.001),
nosocomial infections (p ⫽ 0.01), and ICU mortality (p ⫽ 0.04); p values are for 1994 vs 2001. Used
with permission from Girou et al.34

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 Table 2—Risks of VAP Identified in a Secondary Analysis of Data from the CRIT Study*
Adjusted Odds Ratio
Variables (95% Confidence Interval) p Value

Male gender 1.54 (1.15–2.07) 0.0042

Trauma admission 1.68 (1.15–2.47) 0.0079
Continuous sedation 1.43 (1.07–1.92) 0.0158
Enteral nutrition within 48 h of mechanical ventilation 2.65 (1.93–3.63) ⬍ 0.0001
Parenteral nutrition 3.27 (2.24–4.75) ⬍ 0.0001
Transfusion with 1 to 2 U of RBCs 1.90 (1.28–2.82) 0.0027
Transfusion with ⬎ 2 U of RBCs 1.87 (1.24–2.82) 0.0014
Any transfusion† 1.89 (1.33–2.68) 0.0004
Duration of mechanical ventilation, d 1.50 (1.33–1.70) ⬍ 0.0001
*Data are used with permission from Shorr et al.43 CRIT ⫽ hematocrit and critical care study by Corwin et al.44
†Estimates from a separate model in which any transfusion replaces the categorical transfusion variables.

analysis, NIV independently appeared to exert its time, potentially modifiable. One issue that has
effect on improved outcomes mainly by preventing received little attention, specifically as it relates to
nosocomial infection. A meta-analysis completed by nosocomial infection, is transfusion practice. Several
Burns et al35 contains information about noninvasive studies40 – 42 have suggested that in non-ICU pa-
positive pressure strategies for weaning from me- tients, RBC transfusion heightens the risk for noso-
chanical ventilation and its impact on VAP. comial infection. Similar data are emerging for VAP.
In a secondary analysis43 of data from a large study
Endotracheal Intubation (n ⫽ 4,892) of transfusion practices in critically ill
In addition to avoiding endotracheal intubation, patients,44 RBC transfusions were found to be an
redesigning the endotracheal tube has emerged as an independent risk factor for VAP. Other factors asso-
intriguing option for VAP prevention. Frequently, ciated with VAP included male gender, hospital
the endotracheal tube becomes coated with a bio- admission following trauma, and treatment with
film, which promotes upper airway and, in turn, heavy sedation (Table 2). Of these, RBC transfusions
lower airway colonization. Silver-coating urinary may represent an easily modifiable risk factor, espe-
catheters as a means for limiting the emergence of cially since, in a recent study by Levy et al,45 patients
colonized biofilm reduces urinary tract infections.36 receiving mechanical ventilation received transfu-
A similar approach is currently being studied with sions at higher pretransfusion hemoglobin levels
endotracheal tubes. An animal model of mechanical than patients not receiving mechanical ventilation
ventilation and pneumonia revealed that silver- (8.7 ⫾ 1.7 g/dL vs 8.2 ⫾ 1.7 g/dL, respectively;
coated endotracheal tubes delay host colonization. p ⬍ 0.0001). Strikingly, there seemed to be no one
This decreased propensity for colonization correlates clear reason why patients needing mechanical venti-
with histologic evidence of delayed alveolar neutro- lation received transfusions more often.
phil infiltration and fewer cases of pneumonia.37
Continuous subglottic suctioning of endotracheal
tubes represents another option for preventing VAP
and is potentially attractive since it can be highly Conclusions
cost-effective.38 A recent study39 in which this tech- VAP is a costly and common complication of
nique was combined with semirecumbent position- intensive care. Despite multiple studies investigating
ing, however, showed no clinical benefit.
the diagnosis, treatment, and prevention of VAP,
disagreement and controversy remain. Education of
Transfusion Practice
practitioners about VAP prevention, timing of anti-
All efforts at preventing VAP initially require the biotic treatment, appropriate selection and duration
identification of factors that increase the risk for this of antibiotic regimens, proper identification of pa-
condition. Hand-washing programs, patient position- tients requiring therapy, and counseling against the
ing, avoiding gastric overdistension and nasal intuba- overuse of antibiotics represent several important
tion, maintenance of ventilator and suction devices, strategies to reduce the burden of VAP.
and other VAP prevention strategies all arose from
ACKNOWLEDGMENT: The authors thank William Jackson,
observations that these variables both correlated MD, and Gregory Susla, PharmD, for their helpful comments on
with the diagnosis of VAP and were, at the same earlier drafts of this article.

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www.chestjournal.org CHEST / 128 / 5 / NOVEMBER, 2005 SUPPLEMENT 591S

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 Ventilator-Associated Pneumonia: Insights From Recent Clinical Trials
Andrew F. Shorr and Marin H. Kollef
Chest 2005;128;583-591
DOI: 10.1378/chest.128.5_suppl_2.583S
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