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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 68-75

Ventilator-associated pneumonia: incidence and risk factors in the paediatric intensive care unit


1 Department of Paediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
3 Department of Family Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission21-Jun-2019
Date of Decision24-Jul-2019
Date of Acceptance24-Jul-2019
Date of Web Publication6-Feb-2020

Correspondence Address:
MD Dalia A Latef
Department of Paediatrics, Faculty of Medicine, Sednawy Hospital, Zagazig University
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJOP.AJOP_29_19

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  Abstract 


Background Ventilator-associated pneumonia (VAP) is one of the endless research topics that is always under focus, as it represents a major problem in the medical and surgical ICUs, especially with the growing problem of continuous settlement of resistant bacterial strains that influence all prevention bundles.
Objective The aim of this study was to update the incidence, risk factors, and outcome of VAP in PICU.
Patients and methods This prospective observational study was conducted on 300 cases admitted to the PICU in Zagazig University Hospitals, Egypt. All children were radiologically free means have no abnormal lung aeration findings. And connected to mechanical ventilation due to non-pulmonary cause. Follow-up of the cases was scheduled, and radiological, clinical and laboratory data were obtained throughout their ICU stay and according to their days of MV.
Results The incidence of VAP was 37.56 per 1000 ventilation days of PICU patients. The commonest significant risk factors for VAP among the studied group were reintubation [relative risk (RR)=1.53; 95% confidence interval (CI): 1.01–32.24], exposure to sedation (RR=8.13; 95% CI: 2.05–32.24), rate of suction greater than or equal to 3 h interval (RR=2.72; 95% CI: 1.62–4.54), recumbent position (RR=2.69; 95% CI: 1.54–4.71), interval of oral hygiene (RR=1.84; 95% CI: 1.21–2.8), and ineffective hand hygiene (RR=1.51; 95% CI: 1.01–2.5). Multivariate regression analysis revealed that reintubation, rate of oral hygiene greater than 3 h, and duration of MV greater than 7 days are independent risk factors for VAP. Moreover, there was a nonsignificant relation between presence of VAP and mortality among studied patients.
Conclusions The main risk factors for VAP are reintubation, longevity of MV, and the rate of oral hygiene. Close monitoring and training of all ICU staff is recommended.

Keywords: hygiene, incidence, morbidity, pneumonia, ventilator-associated pneumonia


How to cite this article:
Latef DA, Kamel LM, AbdAllah AM. Ventilator-associated pneumonia: incidence and risk factors in the paediatric intensive care unit. Alex J Pediatr 2019;32:68-75

How to cite this URL:
Latef DA, Kamel LM, AbdAllah AM. Ventilator-associated pneumonia: incidence and risk factors in the paediatric intensive care unit. Alex J Pediatr [serial online] 2019 [cited 2020 Feb 21];32:68-75. Available from: http://www.ajp.eg.net/text.asp?2019/32/2/68/277835




  Introduction Top


Ventilator-associated pneumonia (VAP) is a hospital-acquired pneumonia that occurs in patients on mechanical ventilation (MV) either via endotracheal tube or tracheostomy for more than 48 h [1]. VAP is one of the major causes of morbidity and mortality in Pediatric Intensive Care Units (PICUs). It is associated with a mortality rate of 33–71%, depending on the virulence of the causative pathogen, gestational age, underlying lung pathology, and duration of endotracheal intubation (ETT). Mortality rate of babies with VAP is 3.4 times higher than those without VAP [2].

VAP is one of the most common nosocomial infections in the PICU. Extreme PICU rates have been reported (31.8/1000 ventilator days) [3],[4]. The incidence rate of VAP ranges from 13.2 to 51 per 1000 days of ventilation in latest studies. VAP levels differ from five cases per 1000 days in pediatric patients to 35 cases per 1000 in burn patients, as surgical 1CUs have greater VAP incidence than medical ICUs. The incidence of nosocomial pneumonia in patients admitted to the cardiothoracic ICU was recorded at 21.6%, 14% in surgical ICUs and 9.3% in medical ICUs [5].

The reported risk factors for VAP are host factors like oropharyngeal colonization; gastric colonization; thermal injuries; post-traumatic, postsurgical, immunosuppression; organ failure, and sinusitis or intervention factors such as emergency intubation, re-intubation, tracheostomy, bronchoscopy, nasogastric tube, sedatives, and stress ulcer prophylaxis [6]. The concomitant illness of hospitalized patients places them at risk for nosocomial infection. Variations in the immune function of patients enable pathogens to cause invasive diseases that would not infect healthy people. Many patients in the hospital experience poor nutrition and increase their risk of infection [7].

Diagnosis of an episode of VAP needs integrated data of clinical, radiological and laboratory findings. The most common clinical signs related to VAP refer to modifications in respiratory secretion features, and the quantity and the appearance of purulent mucus in tracheal aspirate (TA). Other constitutional signs may be associated such as hypothermia or hyperthermia and increased work of breathing [8]. It demands a quick identification and initiation of appropriate antibiotic treatment, to avoid the risk of insufficient antibiotic treatment on the patient’s prognosis and the emergence of multidrug-resistant (MDR) pathogen [9].


  Aim Top


The aim of the present study was to evaluate the incidence, risk factors and the outcome of VAP in the PICU, Zagazig University Hospitals, Egypt.


  Patients and methods Top


Study design

This prospective study was carried out in the PICU over the period spanning from June 2016 to January 2018 on 300 children who were admitted to the PICU, Zagazig University Hospitals, with all patients mechanically ventilated through a tracheostomy or endotracheal tube. Written consents were obtained from the patients’ guardians to participate in this study according to the rules of the Ethical Committee in the Faculty of Medicine, Zagazig University, Egypt.

Inclusion criteria: all pediatric patients admitted to the PICU and connected to an MV for more than 48 h were included in this study.

Exclusion criteria: patients undergoing discharge, or those being weaned or experiencing death before passing 48 h on the ventilator, patients admitted due to respiratory infections, and patients with congenital heart disease, congestive heart failure or chronic lung disease were excluded from the study.


  Methods Top


All children were subjected to full history taking (date of admission, demographic data, preliminary diagnosis, cause of ventilation and past history of any chronic diseases, allergies or medication), complete clinical examination and routine laboratory investigations including complete blood count, C-reactive protein, blood culture, and chest radiography were carried out after intubation and 2–3 days after MV, and full sepsis screen was performed in the suspected cases. Chest radiography was initially free at the time of enrolment and was monitored daily for any change in temperature, distress signs or change in the amount or character of suctioned secretions.

VAP is diagnosed in the presence of a combination of clinical, radiological and laboratory criteria. According to CDC, VAP is defined as follows: A pneumonia wherein the patient is on MV for greater than 2 calendar days on the date of event, with day of ventilator placement being day 1, and the ventilator was in place on the date of event or the day before. If the ventilator was in place before inpatient admission, the ventilator day count begins with the admission date to the first inpatient location [10].

According to the clinical findings, VAP manifests in the form of high-grade fever, increased coloured TA through suction, increased work of breathing, dyspnea, increased ventilation parameters, with radiological findings detected by two or more serial chest imaging test results with at least one of the following manifestations: new and persistent or progressive infiltrate; consolidation; cavitation; pneumatoceles.

In patients without underlying pulmonary or cardiac disease, and laboratory findings raising up the probability of infection in the complete blood count, positive acute-phase reactants and procalcitonin, the TA was collected.

Endotracheal aspirates, specimen collection, and culture

Endotracheal aspirates were obtained by endotracheal lavage using normal saline and stored using aseptic technique into sterile leak-proof containers, and laboratory processing was carried out immediately. All aspirates were plated onto blood, chocolate, and MacConkey agars. The plates were examined and organisms identified by the morphology of the colony, gram stain and biochemical reaction. Antibiotic sensitivity testing to organisms that were isolated was carried out. The susceptibility of the isolates to some routinely used antibiotics was determined by the Kirby–Bauer disk-diffusion method [10]. In case of a culture negative result, the TA was considered conclusive for VAP if greater than or equal to 5% of the obtained cells contained bacteria [9].

Statistical analysis

The collected data were statistically analysed using SPSS version 21 (SPSS data: IBM corp. released 2011, IBM SPSS statistics for windows, Version 20.0 Armonk, NY: IBM Corp.). Continuous quantitative variables were expressed as the mean±SD and median (range), and categorical qualitative variables were expressed as absolute frequencies (number) and relative frequencies (percentage). Continuous data were checked for normality by using the Shapiro–Walk test. Independent samples Student’s t-test was used to compare two groups of normally distributed data. The Mann–Whitney test was used to compare two groups of non-normally distributed data. Categorical data were compared using the χ2 test. P value less than 0.05 determined statistically significant results.


  Results Top


Patient’s demographic features

Male individuals represented 65% of the studied patients. Their mean age was 46.4 months and ranged from 1 to 144 months. The commonest underlying diseases that led to PICU admission and MV among our patients after excluding pulmonary causes were neuromuscular diseases among 34% of the patients, followed by 20% who were admitted for central nervous system insults and the same percentage for nutritional disorders. The commonest cause of MV at the PICU was hypoxemic respiratory failure among 58.3% of the patients and among 26.7% for hypercapnic respiratory failure. Concerning their outcome, 62% of the patients were successfully weaned with an average duration of ventilation of 3–19 days. The basic clinical and laboratory data of the patients on admission to the PICU before MV showed that 62% of the patients had a fever and 60% presented with signs of toxemia on admission to the PICU. Most of the patients (96%) showed free chest radiography on admission, the other 4% showed signs of pulmonary edema and collapse ([Table 1]).
Table 1 Demographic, clinical and laboratory data of the studied patients on admission

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VAP incidence was calculated as follows: (number of cases with VAP/total number of patients who received MV×100)=67/300×100VAP rate per 100 patients. 67/300×100=22.3% VAP incidence density was calculated as follows: (number of cases with VAP/number of ventilator days)×1000=VAP rate per 1000 ventilator days 67/(1784)×1000=37.56 per 1000 ventilator days.

In this study, 38% of VAP patients had sterile TA on culture and sensitivity, while the commonest organism detected among positive culture patients was Staphylococcus aureus in 46.3% of the patients, followed by  Escherichia More Details coli and Klebsiella pneumoniae (14.9%) for each of them. Streptococcus pneumoniae represented 13.4%, gram-positive streptococci 7.4% and, lastly, actinobacter (3.1%) ([Figure 1]).
Figure 1 Pie chart showing distribution of micro-organisms among ventilator-associated pneumonia patients as regards the result of tracheal aspirate.

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On studying the relation between demographic characteristics and incidence of VAP, there was a statistically nonsignificant difference between VAP and non-VAP patients with regard to their sex. Yet, there was a high statistically significant difference between patients who developed VAP in comparison with those who did not develop VAP as regards age and length of ventilation stay, as it showed that patients of younger age and having a longer duration of MV had a higher risk for developing VAP ([Table 2]).
Table 2 Comparison between demographic characteristics and ventilation duration among ventilator-associated pneumonia and nonventilator-associated pneumonia patients

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The commonest significant risk factors for VAP among studied group were as follows: reintubation [relative risk (RR)=1.53; 95% confidence interval (CI): 1.01–32.24], exposure to sedation (RR=8.13; 95% CI: 2.05–32.24), rate of suction greater than or equal to 3 h interval (RR=2.72; 95% CI: 1.62–4.54), recumbent patient position, (RR=2.69; 95% CI: 1.54–4.71), interval of oral hygiene greater than or equal to 3 h (RR=1.84; 95% CI: 1.21–2.8), and ineffective hand hygiene (RR=1.51; 95% CI: 1.01–2.5) ([Table 3]).
Table 3 Univariate analysis of the possible risk factors predisposing to ventilator-associated pneumonia in the studied patients

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Multiple logistic regression analysis showed that oral hygiene interval (≥3 h) is a very important risk factor for VAP, as it increased the risk for developing VAP among the studied patients by 205.23 folds; moreover, reintubation significantly increased the risk for VAP by 14.58 folds. The increasing duration of ventilation increased that risk by 4.46 times ([Table 4]).
Table 4 Multivariate analysis for factors independently associated with occurrence of ventilator-associated pneumonia among the studied children admitted to the PICU and who underwent MV

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As regards the outcome of the studied patients, our study showed a nonsignificant relation between the presence of VAP and mortality ([Figure 2]).
Figure 2 Combined bar chart showing a nonsignificant relation between presence of ventilator-associated pneumonia and mortality among the studied patients (P=0.292).

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  Discussion Top


The significance of studies that define the risk factors for nosocomial infections, especially in critical infants, cannot be undermined, as they significantly help in providing effective preventive measures and formulating policies in the pediatric intensive care setting [11].

In this study, the incidence of VAP was 22.3 per 100 of the studied patients and 37.56 per 1000 ventilation days of PICU patients among our studied groups. Late extubation, ignored oral hygiene and lack of appropriate implementation of the VAP prevention bundle may have contributed to higher VAP incidence in the present study.

In developing nations with restricted resources, VAP incidence rates are greater. Different Indian studies showed that VAP rates ranged from 20 to 36.2% in children ventilated in the PICUs [4],[12],[13]. Gupta et al. [14] demonstrated an incidence of VAP of 17.5%. An Egyptian study showed that the overall rate of hospital acquired infection (HAIs) was 24.5% and that of VAP was 31.8 per 1000 ventilator days [3]. El-Kholy et al. [15] revealed that among 490 pediatric patients, VAP was the most frequently found device-associated nosocomial infection (90%). Another domestic multicenter research on nosocomial diseases in Spain revealed a very small prevalence of VAP (1.3%) among mechanically ventilated children in the PICU [16]. Bozorgmehr et al. [17] found that the VAP incidence was 11% among patients in their study, and VAP-related mortality was estimated to be 78.9%. A higher rate was also reported by Gadappa and Behera [11] wherein 40% of their patients had VAP. A report from Thailand has quoted the incidence of VAP at 50% (70.3 cases/1000 days on the ventilator) [18], while a Chinese report declared that the incidence was 20.1% [19]. The difference in incidence between centers could be explained by many factors such as original diagnosis and gestational age. In the study carried out by Badr et al. [5], it was relatively higher, 32 neonates of 56 neonates had VAP with an incidence of 57.1%.

In this research, there was a significant relationship between the length of MV and the growth of VAP, which may be explained by the reality that extended MV length increases the danger of infection due to exposure to humidifiers, nebulizers and ventilator circuits that are proven to be an important source and medium for micro-organisms [19]. Prolonged ETT and MV change the bacterial colonization of the respiratory tract, and lead to pneumonia and even sepsis [5].

Two significant mechanisms are considered to involve the pathogenesis of VAP: bacterial colonization of the aerodigestive tract and the aspiration of contaminated secretions into the airways. The ETT is believed to play a prominent role in the development of these mechanisms, not only by incorporating oropharyngeal contents into the airways at the moment of ETT positioning in the airways, but also by acting as a ‘bridge’ for bacteria to move from the oropharynx to the lower airways. Furthermore, there is growing proof that the biofilm created on the surface of the ETT may serve as a reservoir from which bacteria are seeded continually into the lower respiratory tree [20].

In another study carried out by Yuan et al. [19], 259 patients were ventilated for more than 48 h. They found that VAP occurred at higher significant rates among prolonged mechanically ventilated PICU patients and was fastened to care procedures such as reintubation and endotracheal suctioning. Badr et al. [5] reported that patients with VAP showed significantly higher duration on MV.

Apisarnthanarak et al. [20] explained it from another view: patients with VAP had a significantly prolonged duration of stay in the PICU and more exposure to resistant pathogens. Koff et al. [21] found no significance as regards length of ICU stay and VAP. Mona et al. [22] reported statistical significance in both length of hospital stays and duration of MV in the studied population.

In this study, 38% of the studied patients showed sterile TA on culture and sensitivity, and it is notable that the commonest organism detected among culture positive patients was S. aureus (27.9 %), followed by E. coli and K. pneumonia (9.7%) for each of them.

In contrast with other studies in which different strains predominated, such as Klebsiella spp. in the study by Khattab et al. [23], Koksal et al. [24] while Acinobacter spp. was the most prevalent causative agent. Petdachai [18] revealed that the Pseudomonas spp. was isolated as the most prevalent organism. Grossman and Fein [25] reported that the sensitivity of quantitative endotracheal culture ranges from 38 to 100%. Zhu et al. [26] reported that, among the patients in their study, the detection rate of gram-negative bacilli was 76.9%, followed by gram-positive coccus (17.9%) in VAP patients. Furthermore, in a study carried out by Yuan et al. [19], they found that the pathogens were mainly gram-negative bacteria (82.1%), namely Pseudomonas aeruginosa, K. pneumonia, and Acinetobacter spp., which were the predominantly detected pathogens. Bozaykut et al. [27] reported that the most common pathogens in the endotracheal aspirate culture were the gram-negative bacilli (76.7%), and, among them, Klebsiella spp. (54.6%) was dominantly isolated. Badr et al. [5] observed that gram-negative bacteria were isolated from the majority of VAP cases (68.6%), and the positive cultures were predominately comprised of Klebsiella spp. (34.3%).

A broad range of nosocomial infections in the ICU involves gram-negative bacilli. Their emergence as major pathogens seems to be partially linked to the extensive use of broad-spectrum antibiotics and partially to their capacity to quickly build resistance to main antibiotic organizations [28]. Shaw proved in his study the predominance of gram positive bacteria with prominent S. aureus, Acinetobacter baumannii and Methicillin resistant S. aureus (MRSA). The predominant isolate of aureus [29]. Acinetobacter baumannii and Methicillin-resistant S. aureus (MRSA) were the most common organisms followed by Enterococcus spp. in those with early VAP, while P. aeruginosa was mostly noted in late VAP [11].

The most significant risk factors for VAP were exposure to sedation, rate of suction, change in ventilation circuit, recumbent position and rate of hand and oral hygiene, with increased risk among patients exposed to these factors in our study. This is in agreement with other previous studies [4],[30].

A total of eight studies were identified in one meta-analysis, including 370 cases and 1071 controls. The authors found ten risk factors that were related to neonatal VAP. The following were the risk factors listed in order by odds ratios (ORs): length of stay in the NICU (OR: 23.45), reintubation (OR: 9.18), enteral feeding (OR: 5.59), MV (OR: 4.04), transfusion (OR: 3.32), low birth weight (OR: 3.16), premature infants (OR: 2.66), parenteral nutrition (OR: 2.30), bronchopulmonary dysplasia (OR: 2.21), and tracheal intubation (OR: 1.12) [31].

Cernada et al. [7] mentioned several neonatal VAP risk factors, including low birth weight, extended MV, sedation opiate therapy, frequent suction and reintubation, bloodstream infection, and steroid use, all associated with enhanced VAP danger. Infants with low birth weight have an immature immune system that puts them at enhanced danger of nosocomial disease. In addition, their skin and mucous membranes are more permeable and are less effective barriers.

The outcome of VAP-positive patients in our study was death in 41.9% compared with 31.6% among VAP-negative patients, but this difference was not statistically significant. This was in agreement with a previous study [32]. However, Apisarnthanarak et al. [20] reported that VAP and prolonged MV have been associated with increased mortality.

Koff et al. [21] discovered no distinction in patient mortality between periods of time.

Being prospective in nature is an important strength of our study. This helped us to highlight risk factors and can help us plan to prevent or lessen the incidence of VAP. Yet, it still had some limitations such as the relatively small sample size and being held in a single centre.


  Conclusion Top


The prevalence of VAP in our PICU is comparatively large. The commonest significant risk factors for VAP were reintubation, frequency of oral hygiene, exposure to sedation, rate of suction, and effectiveness of hand hygiene. We recommend strict implementation of handwashing training program, the application of VAP bundle prevention program, as regards the positioning, suction frequency and technique, and regular training programs about infection control guidelines and recommendations to health care staff.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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