Ventilator-acquired Pneumonia Literature Review

Ventilator-acquired Pneumonia Literature Review

Ventilator-acquired pneumonia (VAP) is among the most common nosocomial infections in patients admitted to the Intensive care unit (ICU). While intubation is a necessity in supporting respiration, it acts as a conduit through which micro-organisms access the lower respiratory tract causing VAP. In addition, other risk factors such as advanced age, reduced immunity, immobility, and supine position increase the risk of VAP. Consequently, VAP negatively affects patient outcomes while increasing the rate of morbidity, mortality, and hospitalization. The cost of care is also increased. In some cases, the bacteria develop resistance to bacteria, causing a challenge in the management. Therefore, there is a need to adopt a nurse-led initiative that will help in preventing VAP. Various methods have been used. However, there is strong evidence supporting the use of Chlorohexidine (CHG) in reducing microbial load, preventing VAP, and improving patient outcomes. Such findings have been supported by the literature review I conducted on my PICOT question. Therefore, I recommend the adoption of using CHG to prevent VAP in my institution. This paper will discuss the comparison of the research questions, sample populations, limitations, and the usefulness of the evidence in my project.

PICOT: In adult patients intubated in ICU (P), how does daily use of Chlorohexidine (I) compared to not using (C) reduce the risk of Ventilator Acquired Pneumonia (VAP) (O) over three months? (T)

Comparison of Research Questions

Various studies have focused on different aspects regarding ventilator-acquired pneumonia. For instance, Deschepper et al. (2018) sought to find out the role of CHG in reducing mortality. The question stated, ‘Does the use of chlorohexidine oral care in critical and non-critical patients reduce mortality? D’Journo et al. (2018) stated ‘does the use of CHG prevent respiratory complications post-surgery for patients with lung cancer? In a meta-analysis by Jackson and Owens (2019), the authors analyzed various randomized control trials (RCT) to assess the effectiveness of CHG in reducing VAP among intubated patients. In another study by Pallotto et al. (2019), the research question stated, ‘can the use of a soap-like solution of 4% CHG followed by water rinsing reduce the incidence of hospital-acquired infections (HAIs) in ICU patients? Compared to a study by Reagan et al. (2019), which used mathematical analysis to determine the effectiveness of using CHG to reduce the incidences of HAIs and the cost of care, the study by Triamvisit et al. (2021) posed the question of whether the use of modified VAP-care bundle reduces the risk of VAP in neurosurgical patients. Finally, (Urbancic et al. (2018) stated; `does the use of CHG compared to triclosan reduce the rates of HAIs in ICU patients?

Comparison of Sample

The studies presented in the literature were done in different settings for patients with various needs and characteristics. However, it was common for most studies that the sample population comprised of patients admitted to the ICU while nurses intervened for most of the care. Sampling methods and numbers differed in various studies. A retrospective observational study by Deschepper et al. (2018) sampled 82,274 patients while 11,113 patients received CHG. Despite being done in different settings, studies by D’Journo et al. (2018) and Pallotto et al. (2019) sampled 450 patients each and used simple randomization to divide patients into either control or intervention groups.  On the other hand, Reagan et al. (2019) simulated 850 patients from a single center using a mathematical model to analyze the cost of care. Triamvisit et al. (2021) recruited 291 patients from two neurosurgical ICU units. Simple randomization was used to classify 146 participants as control, while 145 formed the cohort group. Finally, a study by Urbancic et al. (2018) followed a total sample of 4262 ICU admissions and compared outcomes.

Comparison of Study Limitations

Despite the literature yielding relevant information, several limitations were highlighted. First, adherence to evidence-based practice (EBP) was a challenge to some nurses leading to incomprehensive results. Some nurses were resistant to change while opting to continue with their prior practices. Furthermore, it wasn’t clear how frequently should CHG be applied to enhance its effectiveness. In addition, the acquisition of resources proved futile in some centers, thus limiting the implementation process. Finally, studies had smaller sample sizes that could not represent the whole population.

Conclusion and Recommendations

            Despite VAP being among the common nosocomial infection that impairs patient outcomes, the use of CHG has proved effective in reducing mortality and morbidity associated with it. The ability of CHG to inhibit cell wall integrity makes it effective against both gram-negative and gram-positive bacteria, the major cause of VAP. Therefore, there is a need to equip all nurses with the necessary knowledge on how to apply CHG and adhere to the protocols to prevent VAP. However, future research should focus on studying issues around the frequency of bathing with CHG, the effectiveness of the various concentrations in reducing VAP, and the adverse effects associated with CHG use. Finally, more randomized control studies should be done while including larger sample sizes that represent the entire population. Essentially, having credible evidence will enhance the adoption of the EBP in various ICU settings and improve healthcare outcomes.

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References

Deschepper, M., Waegeman, W., Eeckloo, K., Vogelaers, D., & Blot, S. (2018). Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide, observational cohort study. Intensive Care Medicine, 44(7), 1017–1026. https://doi.org/10.1007/s00134-018-5171-3

D’Journo, X. B., Falcoz, P.-E., Alifano, M., Le Rochais, J.-P., D’Annoville, T., Massard, G., Regnard, J. F., Icard, P., Marty-Ane, C., Trousse, D., Doddoli, C., Orsini, B., Edouard, S., Million, M., Lesavre, N., Loundou, A., Baumstarck, K., Peyron, F., Honoré, S., … Thomas, P. A. (2018). Oropharyngeal and nasopharyngeal decontamination with chlorhexidine gluconate in lung cancer surgery: a randomized clinical trial. Intensive Care Medicine, 44(5), 578–587. https://doi.org/10.1007/s00134-018-5156-2

Jackson, L., & Owens, M. (2019). Does oral care with chlorhexidine reduce ventilator-associated pneumonia in mechanically ventilated adults? British Journal of Nursing (Mark Allen Publishing), 28(11), 682–689. https://doi.org/10.12968/bjon.2019.28.11.682

Pallotto, C., Fiorio, M., De Angelis, V., Ripoli, A., Franciosini, E., Quondam Girolamo, L., Volpi, F., Iorio, P., Francisci, D., Tascini, C., & Baldelli, F. (2019). Daily bathing with 4% chlorhexidine gluconate in intensive care settings: a randomized controlled trial. Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases, 25(6), 705–710. https://doi.org/10.1016/j.cmi.2018.09.012

Reagan, K. A., Chan, D. M., Vanhoozer, G., Stevens, M. P., Doll, M., Godbout, E. J., Cooper, K., Pryor, R. J., Hemphill, R. R., & Bearman, G. (2019). You get back what you give: Decreased hospital infections with improvement in CHG bathing, mathematical modeling, and cost analysis. American Journal of Infection Control, 47(12), 1471–1473. https://doi.org/10.1016/j.ajic.2019.07.003

Triamvisit, S., Wongprasert, W., Puttima, C., Chiangmai, M. N., Thienjindakul, N., Rodkul, L., & Jetjumnong, C. (2021). Effect of a modified care bundle for prevention of ventilator-associated pneumonia in critically-ill neurosurgical patients. Acute and Critical Care, 36(4), 294–299. https://doi.org/10.4266/acc.2021.00983

Urbancic, K. F., Mårtensson, J., Glassford, N., Eyeington, C., Robbins, R., Ward, P. B., Williams, D., Johnson, P. D., & Bellomo, R. (2018). Impact of unit-wide chlorhexidine bathing in intensive care on bloodstream infection and drug-resistant organism acquisition. Critical Care and Resuscitation: Journal of the Australasian Academy of Critical Care Medicine, 20(2), 109–116. https://pubmed.ncbi.nlm.nih.gov/29852849/

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While the implementation plan prepares students to apply their research to the problem or issue they have identified for their capstone project change proposal, the literature review enables students to map out and move into the active planning and development stages of the project.

A literature review analyzes how current research supports the PICOT, as well as identifies what is known and what is not known in the evidence. Students will use the information from the earlier PICOT Question Paper and Literature Evaluation Table assignments to develop a review (750-1,000 words) that includes the following sections:

Title page
Introduction section
A comparison of research questions
A comparison of sample populations
A comparison of the limitations of the study
A conclusion section, incorporating recommendations for further research
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.