Zapping VAP

Vol. 22 • Issue 7 • Page 9

Hanging on a wall in the respiratory care department at Community Hospital in New Port Richey, Fla., is a plaque that reads: “Success is never an accident. It is always the result of high intentions, sincere effort, intelligent direction and skillful execution.”

Success in this case was 14 months without a single case of ventilator-associated pneumonia (VAP) in a 389-bed acute care facility that averages seven vent cases a day.

Department Chief Bill Seigler, CRT, lauded his RTs for earning the Patient Safety Award but added: “We couldn’t have done it without the participation of the nurses.”

Community Hospital is hardly alone in stepping up efforts to combat nosocomial infections like VAP. Last year, officials at the Centers for Medicare and Medicaid Services threatened to withhold payment for extended hospital stays due to VAP. They later withdrew their threat-but promised to revisit the issue.

Hospitals have another pressing reason to reduce VAP: Research and development of new antibiotics to fight Pseudomonas, the most common VAP infection, have stalled, experts say. Food and Drug Administration (FDA) officials are so stingy in approving new antibiotics for VAP that some frustrated pharmaceutical firms are leaving the antibiotics field, according to some drug researchers.

Literature Review

One expert sounding the alarm is Richard Wunderink, MD, a professor in the division of pulmonary and critical care at the Feinberg School of Medicine, Chicago.

Speaking at CHEST ’08 in Philadelphia, Wunderink reviewed a 2008 randomized trial that found combination antibiotic therapy no better than monotherapy in reducing 28-day mortality among 740 mechanically ventilated patients suspected of having VAP.1

Another 2008 trial compared the investigational drug doripenem with an older drug, imipenem, and found no mortality difference and no adverse event difference, although doripenem led to lower resistant Pseudomonas, Wunderink said.2Despite that study, FDA officials denied doripenem an indication for combating VAP.

The agency wants superiority, not merely equivalence, before granting new antibiotics the VAP indication, Wunderink said, adding: “The FDA is emphasizing mortality rather than clinical cure. Yet only one drug (Linezolid) has shown a mortality benefit, and the FDA has criticized that drug as well.”

Calling himself “relatively pessimistic,” Wunderink concluded: “There are pharmaceutical companies leaving the antibiotic market because of the FDA. We need to plan on not having any new antibiotic drugs in the future. We need to make better use of the drugs we have and avoid overusing them.”

Closed Circuits

Like other respiratory directors, Seigler has taken several non-pharmaceutical steps to reduce VAP. “We looked at how many times we opened the patient’s circuit when disconnecting them from the vent for suctioning or doing lavage and tried to eliminate opening closed circuits as much as possible,” he said.

He purchased catheters designed to avoid opening ventilator circuits, spring-loaded T-valves that allow for nebulizer treatments while keeping circuits closed and endotracheal tubes with cuffs that blow up to seal off the trachea.

“Many patients probably don’t get the oral care they need” and some secretions contains pathogens, Seigler explained. “With this little port above the balloon, we can suction off secretions so they won’t drain into the trachea.”

He also switched to heat-moisture exchangers, extended circuit changes from three to seven days and adopted a weaning protocol to decrease vent days.

Many hospitals still struggle to instill a low-tech but tried-and-true VAP controller: routine hand-washing, said Mike Reno, vice president of St. Luke’s Episcopal Hospital, Houston.

“Hospital leadership must set the tone by holding all caregivers, including physicians, accountable for practicing proper hand hygiene, and then develop an effective monitoring mechanism for compliance,” he said. “It is also crucial that facilities provide an adequate number of sinks, soaps and waterless hand disinfectants for caregivers to use.”

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Contact Michael Gibbons at [email protected].