Logistic regression analysis identified 4 factors independent associated with VAP ..... Also Tripath et al 2010 [9] showed that the mean length of NICU stay was ...
Ventilator-Associated Pneumonia in Neonatal Intensive Care Unit: Characteristics, Risk Factors and Outcome Safaa A. ELMeneza; Amal Gaber and Awatef A. Al Refaey.
Departments of Pediatrics, Faculty of Medicine, Al-Azhar University, Egypt.
Azhar j of pediatrics, Volume 3, No 2 June 2010
Abstract: Background: Ventilator-associated pneumonia (VAP) is the second most frequent hospital-acquired infection in critically ill neonates which occurs in people who are on mechanical ventilation through an endotracheal or tracheostomy tube for at least 48 hours and which was not developing at the time of admission. The objectives: of this study were to determine the rate, risk factors, causative agents, and outcome of VAP in neonates hospitalized in NICU of ALzhraa University hospital. Methods: A prospective observational study including 91 ventilated newborn infants was conducted from May 2009 to April 2010 in the newborn intensive care unit of AL Zhraa University hospital, Cairo, Egypt. The modified criteria for VAP from CDC for infants less than one year were applied. The medical records of all cases were reviewed prospectively. All the demographics data, the underlying diseases, medications and procedures were recorded and the risk factors were evaluated from the time of admission until the onset of VAP; previous BSI or late sepsis, central venous or umbilical catheter and numbers of ETT attempts were considered as risk factors. The main outcomes measured were VAP, hospital length of stay and mortality. Results: VAP occurred in 29 newborn infants out of the 91 ventilated cases; 31.8%. Rate of VAP was 43.2/ 1000 ventilator days. Newborn infants with VAP had longer duration on ventilator (12.03 ± 1.1days vs 5.2 ±0.06 days and longer hospital stay. The study revealed that the following factors were associated with VAP; prematurity, low birth weight, duration of umbilical catheterization, respiratory distress syndrome and number of intubations .The most common clinical symptoms associated with VAP included Increase respiratory secretion, desaturation and alternative episodes of hypothermia/hyperthermia . Gramnegative organisms were the major cause of VAP in this study. Some cases had polymicrobial microorganism. There was significant decrease in GA of VAP cases than non VAP cases, P= 0.04. The percentage of cases < 37 weeks of gestation was 72.4% from total of VAP group which different significantly from non VAP group P =0.03.
Logistic regression analysis identified 4 factors independent associated with VAP; prematurity, respiratory distress syndrome reintubation and duration of mechanical vent Conclusions: VAP is one of the important hospital acquired infection in our NICU that need improvement and institution of infection control bundle. The risk factors include prematurity, low birth weight, respiratory distress syndrome, repeated ETT, and increased duration of UVC.
Abbreviations: (VAP)=Ventilator neonatal intensive care unit
associated
pneumonia,(NICU)=
INTRUDUCTION: Ventilator associated pneumonia (VAP) is defined as hospital acquired pneumonia occurring in patients receiving mechanical ventilation through an endotracheal or tracheostomy tube that develops more than 48 hours after initiation of mechanical ventilation and which was not developing at the time of admission. [1]. VAP is the second most common nosocomial infection in neonates. It is associated with increased duration of hospital stay resulting in high morbidity and mortality among neonatal intensive care unit (NICU) patients, with an estimated incidence of 6% – 32% [2-4]. VAP arises from aspiration of secretions, colonization of the reodigestive tract, the use of contaminated equipment, or medications. [5]. Risk factors for VAP include prematurity, very low birth weight, severe underlying disease, prolonged duration of mechanical ventilation, use of wide spectrum antibiotics, prolonged hospital stay, inadequate pulmonary toilet, and extensive use of invasive devices and procedures [4,5]. CDC definition for VAP exists for infants < 1 year of age, but not specific for low- or very-low birth- weight infants. [6] These patients often have co morbidities such as bronchopulmonary dysplasia, hyaline membrane disease, blood stream infections (BSIs), and necrotizing enterocolitis that obscure clinical, laboratory, and radiographic evidence of VAP. Newborn infants have different anatomy, physiology, and underlying diseases and exposed to different invasive procedures compared with adults, therefore there is need to study the risk factors and etiology for VAP in ventilated neonates.
The objectives of this study were to determine the rate, risk factors, causative agents, and outcome of VAP in neonates hospitalized in NICU of ALzhraa University hospital.
Patients and Methods: A prospective observational study was conducted in the newborn intensive care unit of AL Zhraa University hospital, Cairo, Egypt from May 2009 to April 2010. It is terciary hospital, has 24 incubators and 8 ventilators. The study included 91 neonates who received mechanical ventilation by orotracheal tube for a period of > 48 hrs because of different illnesses. Neonates requiring MV for less than 48 hours and those who had pneumonia at the time of initiation of MV were excluded from the study. Diagnosis of VAP was based on the criteria recommended by the CDC for infants less than one year of age, as follows: i) pneumonia that develops later than 48 hrs. after initiation of mechanical ventilation; ii) patients with underlying disease require at least 2 serial chest radiographs with 1 of the following: new or progressive and persistent infiltrate, consolidation, Cavitation, pneumatoceles. In patients without underlying disease( e.g. RDS,BPD),a single chest radiograph must show at least 1 of the previous changes; iii) worsening gas exchange and at least three of the following criteria: temperature instability with no other recognized cause, new onset of purulent sputum, increase in respiratory secretions or increased need for suctioning, WBC < 4000/mm3 or >15000/mm3, respiratory signs (apnea, tachypnea, nasal flaring, retraction, wheezing, rales and ronchi), and bradycardia or tachycardia [4]. All patients were subjected to the following protocol: All patients were ventilated by orotracheal tube, which was changed only if, blocked or displaced. Patients were ventilated in SIMV mode using B Babylog 8000-plus Drager ventilator with heated humidification system. One set of disposable ventilation circuit was used for one patient. Open method of suction was used for suctioning of secretions. Patients were ventilated in supine position with frequent changing to right lateral and left lateral position and nasogastric tube was put in all patients. Any hyperthermia (>380C) or hypothermia ( 5days Underlying diseases
2368.9 ± 113
2972 ± 825
0.047
26 3
58 4
0.4
RDS PA Early sepsis MAS
17 (58.6 %) 4 (13.8%) 6 (20.7%) 2 (6.9%)
16 (25.9 %) 10 (16.2%) 30 (48.3%) 6 (9.6%)
BSI Umbilical catheter (days) Number of ETT reintubation Duration of umbilical catheter (days)
10(34.5%) 22(75.9%) 9.5 ±0.9
35(56.5%) 38(61.3%) 2.5±0.3
0.08 0.25 0.001
3.5± 2.9
2.4±2.9
0.04
0.019
Table 2: Clinical Symptoms and Laboratory Characteristics of VAP Clinical:
VAP N(%)
Fever (>38°C)
9(31%)
Hypothermia (
