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Correspondence |

Prevention and Diagnosis of Ventilator-Associated Pneumonia: A Regional Survey in Italy FREE TO VIEW

Francesco G. De Rosa, MD; Marianna Michelazzo, MD; Nicole Pagani, MD; Giovanni Di Perri, MD, PhD, DTM&H; V. Marco Ranieri, MD, PhD; Bruno Barberis, MD
Author and Funding Information

Affiliations: University of Torino Torino, Italy,  Ospedale di Rivoli Rivoli, Italy

Correspondence to: Francesco G. De Rosa, MD, Clinica Malattie Infettive, Ospedale Amedeo di Savoia, Corso Svizzera 164, 10149 Torino, Italy; e-mail: francescogiuseppe.derosa@unito.it


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(3):881-882. doi:10.1378/chest.08-2763
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The rate of application of preventive and diagnostic strategies in the management of patients with ventilator-associated pneumonia (VAP) may be significantly different from those reported in international guidelines. We are reporting in this correspondence the results of a regional Italian survey of preventive and diagnostic strategies for the management of patients with VAP in the setting of the 24 participating ICUs of the Piedmont Intensive Care Unit Network (or PICUN). We used as the main references for discussion the results of a similar survey1 and comprehensive evidence-based clinical practice guidelines for the prevention of VAP.2

The results are shown in Table 1. In our study, there was consistent use of open and closed endotracheal suction systems and of subglottic secretion drainage. Closed suction systems are associated with lower costs, and improved safety of patients and health-care workers.2

Table Graphic Jump Location
Table 1 Nonpharmacologic and Pharmacologic Strategies of VAP Preventive and Diagnostic Techniques*

*Values are given as %. HME = heat-moisture exchanger; PPI = proton pump inhibitor.

†p = 0.01.

‡p = 0.05.

There was a high percentage of subglottic secretion drainage, which is effective in preventing early-onset VAP, as was confirmed by a 2005 metaanalysis.3 It appears that heat and moisture exchangers are less frequently used in our survey compared to the data (54% vs 90%, respectively) from a Spanish study.1 However, this type of humidification is not recommended in the Centers for Disease Control and Prevention guidelines.4 A semirecumbent body position was reported in 87% of patients, which is a lower percentage compared to that reported in the Spanish study.1 Noninvasive ventilation was used as a first-line treatment in 75% of the ICUs in our study.

Antiseptic oral rinses were almost universally used. In our survey, the results of which were similar to those of the Spanish study,1 there was a 100% rate of administration of stress ulcer prophylaxis, although in our study proton pump inhibitors were the agents used most often, as opposed to antihistamine type 2 receptor blockers and sucralfate, which were the agents used most often in the Spanish survey.1 There was a 25% rate of reported clinical diagnosis of VAP, which is notoriously sensitive but not specific and is mostly used in small-sized hospitals, because bronchoscopic procedures were more available in large-sized hospitals. Differently from the Spanish survey,1 there was a wide availability of quantitative cultures among the various participating ICUs, and only one ICU reported the use of qualitative cultures for the diagnosis of VAP.

Our data highlight that there are local differences in the preventive and diagnostic strategies used for the management of patients with VAP. There are enormous possibilities for improving such strategies according to international guidelines. Regional surveys are of the utmost importance in discussing the recommendations from the published evidence and are especially useful in a regional setting, where resources are primarily allocated.

We thank the following members and institutions of the Piedmont Intensive Care Unit Network: Ospedale Civile, Ivrea (Torino), Maria Rosa Salcuni, MD; Ospedale Maggiore, Chieri (Torino), Mastroianni Alessandro, MD; Ospedale Edoardo Agnelli, Pinerolo (Torino), Mauro Pastorelli, MD; Ospedale di Asti (Torino), Silvano Cardellino, MD; Ospedale Mauriziano-Rianimazione Generale, Torino, Giuseppe Spina, MD, and Vincenzo Segala MD; Ospedale Mauriziano-Rianimazione Cardiovascolare, Torino, Marco Ganzaroli, MD; Ospedale San Giovanni Battista-Molinette, Torino, V. Marco Ranieri, MD, Rosario Urbino, MD, and Chiara Bonetto, MD; Ospedale San Giovanni Battista-Molinette-Cardiorianimazione, Torino, Mario Lupo, MD, and Daniela Pasero, MD; Ospedale San Giovanni Battista-Molinette-Neurorianimazione, Torino, Maurizio Berardino, MD, and Fulvio Agostini, MD; Ospedale San Giovanni-Antica Sede, Torino, Laura Musso, MD; Ospedale Martini, Torino, Mauro Torta, MD; Ospedale Civile, Chivasso, Piera Biolino, MD; Ospedale di Savigliano (Cuneo), Giuseppe Vaj, MD; Ospedale Maria Vittoria, Torino, Emilpaolo Manno, MD, and Luciana Faccio, MD; Ospedale Civile, Alessandria, Giorgio Iotti, MD; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Candiolo (Torino), Felicino Debernardi, MD; Centro Traumatologico Ortopedico (CTO), Torino, Ambrogio Della Valle, MD; Ospedale Infantile Regina Margherita, Torino, Paolo Costa, MD; Ospedale Santa Croce, Moncalieri (Torino), Gilberto Fiore, MD; Ospedale Degli Infermi, Rivoli (Torino), Bruno Barberis, MD, Maimiliano Parlanti, MD; Ospedale S. Luigi Gonzaga, Orbassano (Torino), Giulio Radeschi, MD; Ospedale S. Andrea, Vercelli, Edoardo Zamponi, MD; and Ospedale Civile, Acqui Terme (Alessandria), Gian Maria Bianchi, MD.

Sierra R, Benitez E, Leon C, et al. Prevention and diagnosis of ventilator-associated pneumonia: a survey on current practices in Southern Spanish ICUs. Chest. 2005;128:1667-1673. [PubMed] [CrossRef]
 
Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence-based clinical practice guidelines for ventilator- associated pneumonia: prevention. J Crit Care. 2008;23:126-137. [PubMed]
 
Dezfulian C, Shojania K, Collard HR, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med. 2005;118:11-18. [PubMed]
 
Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Morb Mortal Wkly Rep. 2004;53:1-36
 

Figures

Tables

Table Graphic Jump Location
Table 1 Nonpharmacologic and Pharmacologic Strategies of VAP Preventive and Diagnostic Techniques*

*Values are given as %. HME = heat-moisture exchanger; PPI = proton pump inhibitor.

†p = 0.01.

‡p = 0.05.

References

Sierra R, Benitez E, Leon C, et al. Prevention and diagnosis of ventilator-associated pneumonia: a survey on current practices in Southern Spanish ICUs. Chest. 2005;128:1667-1673. [PubMed] [CrossRef]
 
Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence-based clinical practice guidelines for ventilator- associated pneumonia: prevention. J Crit Care. 2008;23:126-137. [PubMed]
 
Dezfulian C, Shojania K, Collard HR, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med. 2005;118:11-18. [PubMed]
 
Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Morb Mortal Wkly Rep. 2004;53:1-36
 
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