Nosocomial pneumonia and the main victim: the older person – measures for ventilator-associated pneumonia control

Introduction

Respiratory infections are responsible for an elevated number of older patient admissions to the ICU, and nosocomial pneumonia (NP) carries a worse prognosis for these patients. Preventive measures are even more important for nosocomial infection control in the case of ventilator-associated pneumonia (VAP).

Materials and methods

A tertiary 205-bed hospital with 650 to 850 admissions/month, more than 65% corresponding to older patient ICU admissions. A preventive VAP package has been established focusing on reduced infection rates due to VAP high lethality in older patients. From October 2008 to January 2009, NP cases were followed and the VAP preventive measures package applied for VAP control: (I) elevation of the head of the bed to 30 to 45°; (II) daily sedative interruption; (III) peptic ulcer disease prophylaxis; and (IV) deep venous thrombosis prophylaxis.

Results

Forty-nine patients had NP, 42 were older than 60 years (85.7%). Seventeen cases were VAP, and 15 were older patients (88.2%). Distribution: October 2008 = 11 cases (90.9% older patients), seven VAP cases (85.7% older patients); November 2008 = six cases (83.3% older patients), two VAP cases (50% older patients); December 2008 = 17 cases (70.6% older patients), two VAP cases (100% older patients); and January 2009 = 15 cases (100% older patients), six VAP cases (100% older patients). The older patients/ICU days (E/ID) rate by month was 91%, 89%, 90% and 80%. The percentage of patients who accomplished all four preventive measures for VAP (all-or-nothing approach), from December 2008 to January 2009: (I) 98.6% to 97.7%; (II) 79.8% to 80.4%; (III) 96.8% to 97.2%; (IV) 97.1% to 95.6%; (76.9% to 78%). Pseudomonas aeruginosa was the most prevalent pathogen (45%). The 50th percentiles for VAP cases/1,000-day MV rates in 2008 varied from 4.74 to 15.89 between ICU units. The NP lethality rate was 8.2%. The older patients' death rate was 75%.

Conclusion

The VAP rate in older patients increased in January probably because of the decrease of the E/ID rate in this month. Our data show that NP and VAP occur mostly among older patients, and implementing VAP preventive measures packages by ICU staff might positively impact NP and VAP outcomes. Our results suggest that VAP rates in these ICUs began to decrease dramatically following the preventive measures package implementation.