VENTILATOR-ASSOCIATED PNEUMONIA AMONG PEDIATRIC INTENSIVE CARE

UNIT PATIENTS AGED 0 TO 18 YEARS ADMITTED IN A PRIVATE TERTIARY

HOSPITAL
AUTHOR: RENIEROSE AGUJETAS, M.D.

OBJECTIVE: This is a retrospective study conducted to determine the incidence of ventilator-

associated pneumonia (VAP) among pediatric patients in the pediatric intensive care unit (PICU)
of a tertiary hospital from January 2013 to August 2013, after the implementation of the VAP
bundle.
METHODS: Prospectively collected data were retrospectively examined from patients’ charts
from the hospital’s records section. The primary outcome measure was development of VAP. The
secondary outcomes were the risk factors for the development of VAP and the outcome of patients
with VAP. Simple percentage was used to determine the distribution of patients in terms of
variables under the demographic profile, and was used to report the frequency of known potential
factors leading to the development of VAP. Chi-Square test for independence was used to test a
significant relationship between profile and the development of VAP and between potential risk
factors and the development of VAP, where e=0.05 = 5% margin error. Incidence proportion is the
proportion of initially VAP-free pediatric patients that developed VAP from January 2013 to
August 2013 and was expressed in percentage.
RESULTS: Of the 24 mechanically ventilated patients, 11 developed VAP (45.83%), and 7
(29.2%) were male and 4 (16.7%) were female; 2 (8.3%) were ≤ 1 year-old, 8 (33.3%) > 1 to 12
years old and 1 (4.2%) > 12 to 18 years old. VAP rate was at 37.16/1,000 ventilator days. The
patients with VAP had mean ventilator-free days of 12 days, mean PICU-free days of 8.27, and
mean hospital length of stay of 38.72. Those without VAP had mean ventilator-free days of 16.07,
mean PICU-free days was 15.84, and mean hospital length of stay was 22. A medical admitting
diagnosis was significantly associated with VAP (p-value 0.047). There were significant
association among the following risk factors and the presence of VAP: (1) prolonged mechanical
ventilation (p-value 0.006 and likelihood ratio p-value 0.002); (2) prolonged PICU stay (p-value
0.015). The length of hospital stay was not significantly associated with VAP (p-value 0.1933).
Other potential risk factors: intubation tube characteristics, route of mechanical ventilation,
medications, nutritional method, transport out of the PICU while ventilated, and having an
underlying pulmonary or cardiac diseases were not significantly associated to VAP. The following
had significant association with VAP: re-intubation (p-value 0.0446) and blood product
transfusion (p-value 0.0405).
CONCLUSIONS: A relatively high rate of VAP was still noted despite the implementation of
VAP bundle and surveillance of adherence to VAP bundle. The identified predictors of VAP were
having a medical diagnosis, reintubation, and transfusion of blood products. Patients intubated
longer were likely to develop VAP. Patients with VAP had longer PICU length of stay. Studies of
interventions to decrease VAP are needed in PICU patients. Prospective review of all patient data
is more likely to determine accurately the VAP rate and risk factors.

1
 INTRODUCTION

Background of the Study

Ventilator-associated pneumonia (VAP) is pneumonia in mechanically ventilated patients that

develops later than or at 48 hours after the patient has been placed on mechanical ventilation. VAP

is the second most common hospital-acquired infection among pediatric and neonatal intensive
1, 2
care unit (PICU and NICU) patients . Evidence-based clinical practice guidelines aimed at

reducing VAP have been present for many years and include several prevention strategies. VAP

bundle is a group of evidence-based procedures, which when grouped together and implemented

as an “all or nothing” strategy, may result in substantial clinical outcome improvement. Since VAP

bundle was introduced there have been several studies that have reported significant VAP rate

reductions.

Significance of the Study

VAP is associated with increased morbidity in PICU patients, specifically, a longer

duration of mechanical ventilation. Evidence-based clinical practice guidelines aimed at reducing

VAP have been available for many years and include dozens of clear prevention strategies.

Awareness of the gap between guideline dissemination and clinical practice has led to efforts by

individual hospitals and health care systems to institute programs aimed at complying with VAP

prevention guidelines to reduce the burden of this nosocomial infection. The bundle approach has

been very successful at effecting evidence based recommendation. 3

2
 When our institution’s ICUs started adapting VAP bundles in November 2012, we would

like to find out the impact it has on the VAP rates. There has been a struggle in coming up with

the right surveillance forms as well as having the ICU staff to comply filling-up the said forms. By

complying with the VAP bundle elements described by the National Nosocomial Infection

Surveillance (NNIS) and Center for Disease Control and Prevention (CDC), we believed that we

could lessen our VAP burden.

Research Objectives

A. General Objective

This is a retrospective study conducted to determine the incidence of ventilator-associated

pneumonia (VAP) among pediatric patients in the pediatric intensive care unit (PICU) of a

tertiary hospital from January 2013 to August 2013, after the implementation of the VAP

bundle.

B. Specific Objectives

1. Determine the demographic profile of the pediatric patients in the PICU as to:

1.1. Sex;

1.2. Age; and

1.3. Admission diagnosis;

2. Determine the incidence proportion of VAP among pediatric patients admitted in the

pediatric intensive care unit;

3
3. Determine the rate of VAP among pediatric patients admitted in the pediatric intensive

care unit

4. Determine the microbial isolates based on results of endotracheal tube, blood, urine, and

other tissue cultures;

5. Determine the outcome of the VAP patients as to:

5.1 Ventilator-free days;

5.2 PICU-free days;

5.3 Hospital length of stay; and

5.4 Final disposition of the patient: discharged improved, or expired

6. Determine if there is association between profile and the development of VAP among

pediatric patients in the PICU;

7. Determine if there is association between the development of VAP among pediatric

patients in the PICU and the following potential risk factors:

7.1. Duration of mechanical ventilation;

7.2. Duration of PICU stay;

7.3. Duration of hospital stay;

7.4. Intubation tube characteristics

7.4.1. Route of mechanical ventilation;

7.4.2. Ventilation tube characteristics;

7.5. Medications

7.5.1. Steroids

7.5.2. Continuous inotropes / vasoactive infusions

7.5.3. Inhaled bronchodilators

4
 7.5.4. Stress ulcer prophylaxis medication

7.5.5. Infusions or doses of sedating medication

7.5.6. Antipyretic

7.6. Nutrition method;

7.6.1. Enteral feeding tubes such as OGT or NGT versus total parenteral nutrition

7.7. Additional procedures

7.7.1. Transfer out of PICU for surgery or imaging studies

7.7.2. Blood product transfusion

7.8. Underlying pulmonary or cardiac disease

5
Definition of Terms

1. Ventilator-associated pneumonia (VAP) – Clinical criteria established by the NNIS and

CDC, pneumonia in mechanically ventilated patients that develops later than or at 48 hours

after the patient has been placed on mechanical ventilation, and have two or more abnormal

chest radiographs with at least one of the following symptoms: new or progressive and

persistent infiltrate, consolidation, cavitation, and/or pneumatoceles (in infants ≤1 year of

age). In patients without underlying pulmonary or cardiac disease (respiratory distress

syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive

pulmonary disease), one definitive chest radiograph is acceptable. In addition to abnormal

chest radiographs, a patient must have at least one of the following symptoms: fever

(>38°C) with no other recognized cause, leukopenia (<4,000 white blood cells

[WBC]/mm3) or leukocytosis (>12,000 WBC/mm3), and at least two of the following

criteria: new onset of purulent sputum, change in character of sputum, increased respiratory

secretions, or increased suctioning requirements; new onset of or worsening cough,

dyspnea, or tachypnea; rales or bronchial breath sounds; and worsening gas exchange (e.g.,

O2 desaturations [e.g., PaO2/ FiO2 levels of ≤240], increased oxygen requirements, or

increased ventilation demand).

For children more than 1 year old up to 12 years of age must meet at least three of

the following criteria: fever (>38.4°C) or hypothermia (<37°C) with no other recognized

cause; leukopenia (<4,000 WBC/mm3) or leukocytosis (≥15,000 WBC/mm3); new onset

of purulent sputum, change in character of sputum, increased respiratory secretions, or

increased suctioning requirements; rales or bronchial breath sounds; and worsening gas

6
 exchange (O2 desaturations [pulse oximetry of <94%], increased oxygen requirements, or

increased ventilation demand).

Infants that are <1 year old must have worsening gas exchange (oxygen

desaturations, increased oxygen requirements, or increased ventilator demand) and at least

three of the following criteria: temperature instability with no other recognized cause; new

onset of purulent sputum, change in character of sputum, increased respiratory secretions,

or increased suctioning requirements; apnea, tachypnea, nasal flaring with retraction of

chest wall, or grunting; wheezing, rales, or rhonchi; cough; and bradycardia (<100

beats/min) or tachycardia (>170 beats/min). NNIS/CDC criteria do not require

microbiologic confirmation to diagnose pneumonia. 3

2. Rates of VAP – the number of VAP cases per 1000 ventilator days

3. Ventilator day – a calendar day for which the patient was charged for mechanical

ventilation

4. Ventilator-free days – duration of unassisted breathing in the first 28 days after onset of

mechanical ventilation

5. ICU-free days – days alive not needing ICU care on the first 28 days after hospitalization

6. Worsening gas exchange – examples are as follows: O2 desaturations (e.g., PaO2/ FiO2

levels of ≤240), increased oxygen requirements, or increased ventilation demand

7
Review of Related Literature

Overall, VAP occurs in 3 to 10% of ventilated PICU patients.4,5 Surveillance studies of

nosocomial infections in NICU patients indicate that pneumonia comprises 6.8 to 32.3% of

nosocomial infections in this setting.3,6,7 In 2004, the NNIS system of the CDC reported a mean
8
VAP rate of 2.9 per 1,000 ventilator days for participating PICUs I the United States. The

incidence of VAP is higher in adult ICU patients, ranging from 15 to 30%. 3

VAP is associated with increased morbidity in PICU patients, specifically, a longer

duration of mechanical ventilation. Fischer et al.12 performed a prospective cohort study to

determine the delay of extubation attributable to VAP among neonates and children undergoing

repair of congenital heart disease. Twenty-six of the 272 patients enrolled over a 22-month period

developed VAP (9.6%). They found that the median delay of extubation attributable to VAP was

3.7 days (average of 5.2 versus 1.5 for patients with and without VAP, respectively). VAP rates

increased dramatically for patients intubated for long periods of time. Among patients extubated

within the first 3 days of surgery, only 4% developed VAP, compared to 40% of postoperative

cardiothoracic surgery patients intubated longer than 30 days. Of the 26 VAP cases, 19 occurred

within the first 3 to 6 days after surgery. 12

Prevention of VAP has become a priority for all ICUs in the United States. The importance

of this issue on prevention of VAP reflects the high incidence and the high cost of treatment
9,10,11
estimated at $11,000 - $57,000. Those patients having VAP spend additional days hooked

on the ventilator and additional days in the ICU and hospital. Adding to the pressure to eliminate

VAP, in the United States, there is an issue that insurance companies may cease to reimburse

8
hospitals for costs incurred as a result of VAP, thus shifting this profound financial burden directly

to hospitals. 11

In a study published in 2010 by D. Bird and colleagues on adherence to VAP bundle and

incidence of VAP in the surgical ICU in Boston Medical Center, their results showed that prior to

initiation of the bundle, VAP was seen at a rate of 10.2 cases/1000 ventilator days. Compliance

with the VAP bundle increased over their study period from 53% and 63% to 91% and 81% in

each respective SICU. The rate of VAP decreased to 3.4 cases/1000 ventilator days. A cost savings

of $1.08 million was estimated.11

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 Research Methodology

A. Study Design

This is a retrospective cross-sectional, descriptive study of pediatric patients aged 0 to 18

years old admitted in the PICU from January 2013 to August 2013.

B. Study Setting

The study was conducted in a tertiary-care, level III hospital, accredited by the Department

of Health that has a 6 PICU bed capacity and admits about 90 patients annually.

C. Study Population:

Inclusion Criteria: All pediatric patients aged 0 to 18 years old who were mechanically

ventilated for 48 hours or more from January 2013 to August 2013.

Exclusion Criteria: The study excluded those who were ventilated less than 48 hours

and those who were ventilated more than 3 days from another institution prior to transfer

to the hospital where the study was done.

D. Sample Size:

Sample size is all pediatric patients aged 0 to 18 years old mechanically ventilated for

48 hours or more in the PICU from January 2013 to August 2013.

10
11
Site Specific Algorithms for Clinically Defined Ventilator-associated Pneumonia

12
Ventilator-associated Pneumonia Diagram for Infants and Children

13
E. Data Collection:

This research protocol was approved by the Institutional Review Board (IRB). A

letter of permission to conduct the same study was submitted to the medical director and

director of patient services to access patients’ scanned charts through the medical records.

Medical records, including charts, progress notes, daily flow sheets, and laboratory

and radiographic reports were reviewed. The demographic data, admitting diagnosis, co-

morbidities, clinical symptoms, laboratory results, medications, hospital outcome, number

of PICU and hospital stay and disposition were recorded. Confidentiality of the patients’

data were addressed.

F. Outcome Measures:

The primary outcome measure is the development of VAP.

The secondary outcome of interest is the risk factors for the development of VAP

and the outcome of patients with VAP.

G. Data Analysis

1. Simple percentage was used to determine the distribution of patients in terms of

different variables under the demographic profile such as Sex, age, and admission

diagnosis. It was also used to report the frequency of known potential factors

leading to the development of VAP.

2. Descriptive statistics such as Mean, SE Mean, Standard Deviation (SD), Minimum

and Maximum Values, Median, Mode were reported to describe the distribution of

patients in terms of different variables under the demographic profile.

14
3. Chi-Square test for independence was used to test if there was significant

relationship between profile and the development of VAP, where e=0.05 = 5%

margin error.

4. Incidence proportion is the proportion of initially VAP-free pediatric patients that

developed VAP from January 2013 to August 2013 and was expressed in

percentage (%). It shall be calculated based on the formula:

Number of new cases of disease or injury during specified period

Size of population at start of period

5. Minitab, a statistical software package, was used in the statistical computations and

analysis of data. Data were entered with Microsoft Excel Spreadsheet and was then

analyzed with Minitab version 16.0.

15
 RESULTS

There was a total of 68 patients admitted in the PICU from January to August 2013. Thirty-

eight (38) of these patients were ventilated but only 24 were mechanically ventilated for ≥ 48 hours

and were eligible for the study. There were 14 (58.33%) males and 10 (41.67%) females in the

study as shown in figure 1. Mean age of the patients included in the study was 57.5 months with

the youngest at 1-day old and the oldest was at 16 years old. There were 17 (70.83%) with a

medical diagnosis and 8 (33%) of these patients had an admitting diagnosis of pediatric community

acquired pneumonia (PCAP) D, followed by dengue shock syndrome, meningitis, status

epilepticus and respiratory distress of the newborn each with 2 (8.33%) patients as shown in table

1.

Figure 1: Distribution of PICU Patients: ventilated and not

ventilated; and males and females

Ventilated < 48 hrs

20%

Ventilated ≥ 48 hrs Females

Males 15%
36%
21%
Not ventilated
44%
Not ventilated
Ventilated < 48 hrs
Males
Females

As to the age distribution there were 5 (20.8%) ≤ 1 year-old, 15 (62.5%) > 1 year old to 12

years old, and 4 (16.7%) > 12 to 18 years old. Table 2 shows that out of the 24 mechanically

16
ventilated patients eligible for the study, 11 developed VAP with an incidence proportion of

45.83%, and 7 (29.2%) of those with VAP were male and 4 (16.7%) were female; 2 (8.3%) were

in the ≤ 1 year-old, 8 (33.3%) > 1 to 12 years old and 1 (4.2%) > 12 to 18 years old. VAP rate was

at 37.16/1,000 ventilator days. Of note was that only 5 out of 11 patients were signed out in the

final diagnosis as having VAP.

Table 1: Patient Characteristics and Underlying Diseases

Demographics Total N=24 %
Sex
Male 14 58.33
Female 10 41.67
Age
≤ 1 y.o. 5 20.8
> 1 y.o. to 12 y.o. 15 62.5
> 12 y.o. to 18 y.o. 4 16.7
Mean age in months
57.5
(Range: 1 day to 16 years old)
Median age in months 24
Admission Diagnosis
Dengue Shock Syndrome 2 8.33
Drowning, S/P Cardiac Arrest 1 4.17
Imperforate anus, TEF 1 4.17
Infectious Diarrhea with severe dehydration 1 4.17
Laryngeal Papilloma 1 4.17
Medulloblastoma 1 4.17
Medulloblastoma, S/P Craniectomy 1 4.17
Meningitis 2 8.33
Multiple physical Injuries sec to MVA 1 4.17
PCAP D 4 16.67
PCAP D, Nephrotic syndrome 1 4.17
PCAP D, status epilepticus 2 8.33
Pneumonia, severe; Status epilepticus 1 4.17
RDS of the newborn 2 8.33
Saccular cyst 1 4.17
Spontaneous pneumothorax, MVP 1 4.17
Substance Abuse, Status epilepticus 1 4.17

17
 Table 2: Distribution of Patients With and Without Ventilator-Associated
Pneumonia
With VAP No VAP Total= 24 (100%)
11 (45.83%) 13 (54.17%)
GENDER
Male 7 (29.2%) 7 (29.2%) 14 (58.3%)
Female 4 (16.7%) 6 (25%) 10 (41.7%)
AGE GROUP
≤ 1 y.o. 2 (8.3%) 3 (12.5%) 5 (20.8%)
> 1 y.o. to 12 y.o. 8 (33.3%) 7 (29.2%) 15 (62.5%)
> 12 y.o. to 18 y.o. 1 (4.2%) 3 (12.5%) 4 (16.7%)

There were 21 tracheal aspirate culture and sensitivity (TACS) done. The most common

growth in all the ventilated patients was Pseudomonas aeruginosa at 4 (19.05%) and followed by

Haemophilus influenzae at 3 (14.3%). The most common growth in patients with VAP is still P.

aeruginosa at 9.6% which appeared 2x in the same patient with 2 separate culture. While in

patients with no VAP the most common TACS growth was H. influenzae at 14.3%. There were 6

patients where no culture of tracheal aspirate was done.

Table 3: Microbiology of Ventilator-Associated Pneumonia: PICU Patients

Tracheal aspirate culture, N = 21 With VAP No VAP Total
Pseudomonas aeruginosa 2 (9.5%) 2 (9.5%) 4 (19.05%)
Pseudomonas oryzihabitans 0 1 (4.8%) 1 (4.8%)
Haemophilus influenzae 0 3 (14.3%) 3 (14.3%)
Streptococcus pneumoniae 1 (4.8%) 0 1 (4.8%)
Klebsiella pneumoniae 1 (4.8%) 0 1 (4.8%)
Escherichia coli 1 (4.8%) 0 1 (4.8%)
Escherichia coli ESBL-producing 0 1 (4.8%) 1 (4.8%)
Acinetobacter baumanii 1 (4.8%) 0 1 (4.8%)
Stenotrophomonas maltophilia 1 (4.8%) 1 (4.8%) 1 (4.8%)
Methicillin-sensitive S. Epidermidis 0 1 (4.8%) 1 (4.8%)
Methicillin-susceptible S. Aureus 0 1 (4.8%) 1 (4.8%)
Viridans streptococci 0 1 (4.8%) 1 (4.8%)
Candida albicans 1 (4.8%) 1 (4.8%) 1 (4.8%)
No growth 4 (19.04%) 2 (9.5%) 6 (28.57%)
TACS not done 1 3 6

Blood culture N = 19
Crytococcus neoformans 0 1 (5.26%) 1 5.26%)
No growth 9 (47.4%) 9 (47.4%) 18 (97.7%)
Culture not done 2 3 5

18
 There was a total of 19 blood cultures done. All of the 9 patients with VAP did not have

growth in their blood cultures while 1 out of the 10 patients without VAP was positive for

Crytococcus neoformans. Table 3 shows the summary of cultures done in the PICU patients

eligible for the study.

Descriptive statistics for the outcome of PICU patients showed the following: mean

ventilator-free days was 12 days and median of 13 days for patients with VAP compared to mean

ventilator-free days of 16.07 and median of 18 days for those without VAP; mean PICU-free days

was 8.27 and median of 7 days for patients with VAP while those without VAP have a mean of

15.84 and median of 17 days; and mean hospital length of stay was 38.72 and median of 26 days

for patients with VAP while those without VAP have a mean of 22 and median of 14 days. As to

the final disposition, 8 (33.33%) of patients with VAP and 10 (41.67%) of those without VAP

were discharged improved; 2 (8.33%) of patients with VAP and 3 (12.5%) of those without VAP

expired; and 1 (4.17%) patient with VAP was transferred to another institution. Table 4 shows a

summary of this descriptive statistics for outcome of the study population.

The researcher wanted to determine if there is any association between patients’ profile

and the development of VAP among pediatric patients in the PICU. Gender was not significantly

associated with VAP with a p-value of 0.63. Age was not also statistically significant with a p-

value of 0.26. It was noted that a medical admitting diagnosis was significantly associated with

VAP with a p-value of 0.047 (Table 5).

19
 Table 4: Descriptive statistics for the outcome of PICU patients
Ventilator-free days
With VAP No VAP All Patients
• Mean (days) 12 16.07 14.21

• Median (days) 13 18 16

PICU-free days
• Mean (days) 8.27 15.84 12.38

• Median (days) 7 17 15

Hospital length of stay

• Mean (days) 38.72 22 29.67

• Median (days) 26 14 18.5

Final Disposition of the patient

• Home 8 (33.33%) 10 (41.67%) 18 (75%)
• Expired 2 (8.33%) 3 (12.5%) 5 (20.83%)
Transfer 1 (4.17%) 0 1 (4.17%)
Total 11 (45.83%) 13 (54.17%) 24

The researcher also determined if there is any association between the development of VAP

among pediatric patients in the PICU and the different potential risk factors. Mechanical ventilator

days were divided into not prolonged (14 days and less) and prolonged (more than 14 days).

Among mechanically ventilated patients, there was a statistically significant association between

prolonged mechanical ventilation and the presence of VAP with a p-value of 0.006 and a likelihood

ratio p-value of 0.002. Same is true when using the ventilator-free days: more than 14 ventilator-

free days versus less or equal to 14 ventilator-free days, which showed a p-value of 0.0446 which

is has a statistically significant association also presence of VAP. Likewise, the association

between prolonged PICU stay and the presence of VAP was statistically significant at a p-value of

0.015. However, the length of hospital stay was not statistically significantly associated with VAP

as shown with a p-value of 0.1933 (table 6).

20
 Other potential risk factors tested such as intubation tube characteristics (cuffed versus

uncuffed), route of mechanical ventilation (orotracheal or via tracheostomy), medications

(steroids, inotropes or vasoactive infusions, inhaled bronchodilators, stress ulcer prophylaxis,

sedating drugs, and antipyretics), nutritional method (enteral versus total parenteral nutrition),

transport out of PICU while ventilated (for procedures), and having an underlying pulmonary or

cardiac diseases or both were not statistically significantly associated to VAP. It was noted

however that the following had statistically significant association with VAP: re-intubation with a

p-value of 0.0446 and blood product transfusion with a p-value of 0.0405 (table 7 and 8).

Table 5: Association between profile and the development of VAP among pediatric
patients in the PICU
Demographics: Gender p-value
VAP Non-VAP
N=11 N=13
Male 7 (6.42) [0.05] 7 (7.58) [0.04]
0.6278
Female 4 (4.58) [0.07] 6 (5.42) [0.06]
Demographics: Age
VAP Non-VAP
</= 1 yr 3 (4.125) 6 (4.875)
> 1 yr to 12 yrs 7 (5.042) 4 (5.958) 0.263

> 12 to 18 yrs 1 (1.83) 3 (2.17)

Admitting Diagnosis and outcome of VAP
VAP Non-VAP
Medical 10 (7.79) [0.63] 7 (9.21) [0.53]
0.047
Surgical 1 (3.21) [1.52] 6 (3.79) [1.29]

21
Table 6: Association between VAP among pediatric patients in the PICU and potential
risk factors
Duration of mechanical ventilation and development of VAP
Ventilator Days-Category VAP No VAP Chi-Square P-Value
Not prolong (≤14 days) 6 13
7.464 0.006
Prolonged (>14 days) 5 0

Duration of ventilation-Free days and development of VAP

≤ 14 Ventilator-free days 7 3
4.033 0.0446
>14 Ventilator-free days 4 10

Duration of PICU and hospital stay and development of VAP

Pearson Chi-
PICU-free days VAP No VAP P-Value
Square
</=14 days 8 3
5.916 0.015
>14 days 3 10
Hospital length of stay
</=14 days 3 7
1.629 0.1933
> 14 days 8 6

Table 7: Association between VAP among pediatric patients in the PICU and potential
risk factors
Intubation tube characteristics:
Pearson Chi-
Route of MV VAP No VAP P-Value
Square
Orotracheal 10 12
Orotracheal and 0.0153 0.901694
1 1
Trachesostomy
Ventilation Tube Characteristic
Cuffed 3 6
0.906 0.341
Uncuffed 8 7
Use of Medications and development of VAP
Steroids 3 (4.12) 6 (4.88) 0.9063 0.3411
Inotropes 5 (3.21) 2 (3.79) 2.6077 0.106343
Inhaled bronchodilator 6 (6.88) 9 (8.12) 0.5483 0.459033

H2 blocker or PPI 7 (7.79) 10 (9.21) 0.5091 0.475512

Sedating drug 8 (7.79) 9 (9.21) 0.0353 0.851054

Paracetamol 3 (5.04) 8 (5.96) 2.8179 0.093216
Nutrition method and development of VAP
Enteral feeding 13 (12.46) 10 (10.54)
1.2332 0.2668
TPN 0 (0.54) 1 (0.46)

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Additional procedures and development of VAP
Re-Intubated 7 (4.58) [1.27] 3 (5.42) [1.08]
4.0328
Not Re-intubated 4 (6.42) [0.91] 10 (7.58) [0.77] 0.044625

Transport out of PICU 4 (4.58) [0.07] 6 (5.42) [0.06]

0.235 0.627867
No transport done 7 (6.42) [0.05] 7 (7.58) [0.04]

Blood transfusion done 8 (5.50) [1.14] 4 (6.50) [0.96]

0.040524
No blood transfusion 4.1958
3 (5.50) [1.14] 9 (6.50) [0.96]
done

Table 8: Association between VAP among pediatric patients in the PICU and potential
risk factors
Underlying pulmonary or cardiac disease and development of VAP
Pearson Chi-
VAP No VAP P-value
Square
With Pulmonary
6 (4.58) 4 (5.42) 1.3858 0.239113
Disease
None 5 (6.42) 9 (7.58)

With Cardiac Disease 1 (1.38) 2 (1.62) 0.2158 0.642271

None 10 (9.62) 11 (11.38)

With Pulmonary &

9 (6.88) 6 (8.12) 3.2336 0.072143
Cardiac Diseases

None 2 (4.12) 7 (4.88)

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 DISCUSSION

The researcher conducted a retrospective cross-sectional, descriptive study to characterize

risk factors and outcomes of VAP and the incidence proportion and rate of VAP among pediatric

patients admitted in the pediatric intensive care unit of a tertiary hospital after the implementation

of VAP bundle and VAP surveillance. A similar retrospective study was done in the same

institution by M.A. Lozada in 2011 covering years 2006 to 2010 prior to the implementation of

VAP bundle and surveillance. That study showed a VAP incidence of 15.6% and VAP rate of 0.98

per 1,000 ventilator days compared to this study results that showed an incidence rate of 45.83%

and a rate of 37.16 per 1,000 ventilator days.13 The probable explanation for this is the different

definition used for onset of VAP in the past study while in this study, the researcher used the

clinical criteria for the diagnosis of VAP established by the NNIS and the CDC.3 Also we can take

into account the differences in interpreting results during chart reviews. A 30-month prospective

surveillance study by M. Almuneef in Saudi Arabia from 2000 to 2002 showed a mean VAP rate

of 8.8/1,000 ventilator days.4 In a study by Elward, published in Pediatrics in 2002, showed that

the VAP rate of 11.6/100 ventilator days (PICU of St. Louis Children’s Hospital, Missouri) is

comparable to this study results. However, our result is higher than the pooled mean VAP rate

reported by the NNIS PICU study with a mean of 6/1000 ventilator days.5

Increased mortality has been associated with infection attributable to Pseudomonas

aeruginosa and Acinetobacter species, more severe underlying illness, and inappropriate antibiotic

therapy.5 The highest age-specific rates of ventilator-associated pneumonia occurred in the 2- to

12-month age group, and the most common causative organism was P. aeruginosa, which

accounted for 22% of cases (13). A study of 20 PICUs in 8 countries performed by the European

24
Multicenter Study Group found that the incidence of nosocomial infection was 23.6% and the most

frequent nosocomial infection was pneumonia (53%). P. aeruginosa caused 44% of ventilator-

associated pneumonia.15 In the study by M. Almuneef, among VAP patients, P. aeruginosa was

the most common organism, followed by Staphylococcus aureus. Other gram-negative organisms

were also encountered.4 Our study showed similar results wherein the most common growth in

patients with VAP is still P. aeruginosa at 9.6% which appeared 2x in the same patient with 2

separate culture.

It is already established in several studies that VAP is associated with longer ICU and

hospital length of stay contributing much the financial burden of the patient. In the study of Elward,

VAP in their PICU patients was associated with a greater than 4-fold increase in PICU length of

stay and a 3-fold increase in hospital length of stay.5 Patients with ventilator-associated pneumonia

also had a higher mortality, which approached statistical significance.5 In our study, PICU patients

with VAP had mean ventilator-free days of 12 days and median ventilator-free days of 13 days;

mean PICU-free days of 8.27 and median of 7 days; and mean hospital length of stay of 38.72 and

median of 26 days.

Risk factor analysis for the development of VAP in this study implies that having a medical

diagnosis is significantly associated with development of VAP (p-value of 0.047) than having a

surgical admitting diagnosis. This result is in contrast to other studies which showed that

postsurgical patients are at higher risk of developing VAP than medical patients. Higher VAP rates

for surgical and trauma ICUs versus pediatric and medical ICUs were reported in the 2004 NNIS

Survey and documented in several adult studies.5 One prospective pediatric study in a tertiary-care

hospital in Saudi Arabia also found surgical patients at significantly higher risk for VAP versus

medical or trauma patients on univariate analysis.4,11 Possible explanation for our result that

25
surgical patients had lower VAP rates compared to medical patients is that these patients had an

elective procedure, were prepared well prior to intubation and surgery and was intubated in a

controlled environment: well sedated and intubated once, no attempts at re-intubation, and thus

less likely that oral and esophageal microorganisms were pushed to the lower respiratory tract

during intubation.

Other risk factors associated with ventilator-associated pneumonia in our population

studied only showed that re-intubation (p 0.0446) and transfusion of blood products (p 0.0405)

were associated with VAP, which were not different from those cited in previous reports. However,

in other studies such as that done by Almuneef, witnessed aspiration, reintubation, continuous

enteral feeding, prior antibiotic therapy, and bronchoscopy were significantly associated with

ventilator-associated pneumonia.4 The study by Lozada done in this same institution at between

2006-2010 showed several risk factors for development of VAP including use of inhaled

bronchodilators and systemic steroids, enteral feeding, reintubation, and positive blood culture

taken on admission or during intubation.13 The small number of population in this present study is

a factor for the differences in risk factors noted from that of other studies having larger population.

Aspiration of oral or gastrointestinal contents is important in the pathogenesis of VAP, as

demonstrated in this and other studies. Reintubation and self-extubation were noted to be risk

factors for VAP, which implicate aspiration during the procedure or incident.4,5

Transfusion was identified as an independent predictor for ventilator-associated

pneumonia in the initial multivariate analysis by Elward.5 They explained that this seemed

biologically plausible as the possible immunosuppressive effects of transfusion have been noted

in other patient populations. In cardiovascular and colorectal surgery patients, transfusion has been

identified as an independent predictor of surgical site infection; the risk of surgical site infection

26
has been shown to increase 7% to 14% with each unit of packed red blood cells transfused.

However, when they retrospectively collected data on the dates and specific types and amounts of

blood products transfused and censored transfusions in patients with VAP that were received after

infection and added these variables to the multivariate analysis, neither the categorical nor the

continuous variables for any type of blood product or for transfusion in general were significant

predictors for VAP. They conclude that the original transfusion variable was likely to be a marker

for another risk factor, such as severity of illness at the time of infection.5 In the prospective study

of Srinivasan published in 2008, they found that the administration of blood products did not

increase the risk factor for VAP. Both a pediatric VAP study and a recent randomized-controlled

trial of blood transfusion strategies in pediatric patients did not find the receipt of blood products

to be an independent predictor of VAP, despite many other studies showing a statistical association

between risk for VAP and blood transfusions.8,16,17

27
 LIMITATION OF THE STUDY

This study has limitations such as the small number of patients included in the study. The

association of receipt of blood products to VAP could not be definitely attributed to the

development of VAP since we did include those patients who were transfused with blood after the

onset of infection. A big factor in the limitation of the study is it being a retrospective chart review

study, which could not really give us the true picture of the patient population since we were only

limited to what was seen in the chart. There could also be a disparity on how we interpret the

results and notes in the patient’s chart. Prospective review of all patient data is more likely to

determine accurately the ventilator-associated pneumonia rate and risk factors.

28
 CONCLUSION

A retrospective study was done to determine rates of, incidence of, risk factors for, and

outcomes associated with ventilator-associated pneumonia in a PICU. A relatively high rate of

ventilator-associated pneumonia was still noted despite the implementation of VAP bundle and

surveillance of adherence to VAP bundle and onset of VAP. The identified predictors of ventilator-

associated pneumonia were having a medical diagnosis, reintubation, and transfusion of blood

products. Patients intubated longer were likely to develop ventilator-associated pneumonia.

Patients with ventilator-associated pneumonia had longer PICU and hospital lengths of stay.

Studies of interventions to decrease ventilator-associated pneumonia are needed in PICU patients.

Prospective review of all patient data is more likely to determine accurately the ventilator-

associated pneumonia rate and risk factors.

29
 BIBLIOGRAPHY

1. Garner, J. S., W. R. Jarvis, T. G. Emori, T. C. Horan, and J. M. Hughes. 1996. CDC

definitions for nosocomial infections, p. A1–A19. In R. N. Olmsted (ed.), APIC infection
control and applied epidemiology: principles and practice. Mosby, St. Louis, MO.

2. Gaynes, R. P., J. R. Edwards, W. R. Jarvis, D. H. Culver, J. S. Tolson, W. J. Martone, and

the National Nosocomial Infection Surveillance System. 1996. Nosocomial infections
among neonates in high-risk nurseries in the United States. Pediatrics 98:357–361.

3. Foglia, E., M. D. Meier, A. Edward. 2007. Ventilator-associated pneumonia in pediatric

intensive care unit patients. Clin. Micro. Reviews. 20:409-425.

4. Almuneef, M., Z. A. Memish, H. H. Balkhy, H. Alalem, and A. Abutaleb. 2004. Ventilator-

associated pneumonia in a pediatric intensive care unit in Saudi Arabia: a 30-month
prospective surveillance. Infect. Control Hosp. Epidemiol. 25:753–758.

5. Elward, A. M., D. K. Warren, and V. J. Fraser. 2002. Ventilator-associated pneumonia in

pediatric intensive care unit patients: risk factors and outcomes. Pediatrics 109:758–764.

6. Drews, M. B., A. C. Ludwig, J. U. Leititis, and F. D. Daschner. 1995. Low birth weight
and nosocomial infection of neonates in a neonatal intensive care unit. J. Hosp. Infect.
30:65–72.

7. Ford-Jones, E. L., C. M. Mindorff, J. M. Langley, U. Allen, L. Navas, M. L. Patrick, R.

Milner, and R. Gold. 1989. Epidemiologic study of 4684 hospital-acquired infections in
pediatric patients. Pediatr. Infect. Dis. J. 8:668–675.
8. Srinivasan, R., Asselin, J., et. al. 2009. A Prospective Study of Ventilator-Associated
Pneumonia in Children. Pediatrics 2009;123:1108-1115

9. Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost of ventilator-
associated pneumonia among intensive care unit patients in a suburban medical center. Crit
Care Med. 2003;31(5):1312-1317.

10. Cocanour CS, Ostrosky-Zeichner L, Peninger M, et al. Cost of a ventilator-associated

pneumonia in a shock-trauma intensive care unit. Surg Infect (Larchmt). 2005;6(1):65-72.

11. Bird, D., A. Zambuto, C. O’Donell, J. Silva, et. al. 2010. Adherence to ventilator-associated
pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical
intensive care unit. Arch Surg.145(5):465-470.

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12. Fischer, J. E., P. Allen, and S. Fanconi. 2000. Delay of extubation in neonates and children
after cardiac surgery: impact of ventilator-associated pneumonia. Intensive Care Med.
26:942–949.

13. Lozada MA. A Retrospective Study on Ventilator-associated Pneumonia Among Pediatric

Intensive Care Patients Admitted in A Tertiary Hospital in Cebu City (2006-2010).
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Surveillance System. Nosocomial infections in pediatric intensive care units in the United
States. Pediatrics. 1999;103(4).

15. Raymond J, Aujard Y, and the European Study Group. Nosocomial infections in pediatric
patients: a European, multicenter prospective study. Infect Control Hosp Epidemiol.
2000;21:260–263

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infections in critically ill patients. Crit Care Med. 2006;34(9):2302–2308

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674

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 APPENDIX

VAP Patient Data Collection Sheet

Name of patient: ___________________________________ Subject No: ________________

Age: ________ Gender: _____________ Patient No: ________________
Date admitted: ________________ Date Discharged: _____________ PTN No: ____________

PICU stay: ____________________ Duration of Hospital Stay: _________________

Admitting diagnosis: ____________________________________________________________________
Final diagnosis: ________________________________________________________________________
______________________________________________________________________________

Date/Time Mechanically Vetilated: _________ Date/Time Mechanical Vetilation Ended: ____________

Chest X-rays reading #1: _______________________

Chest X-ray reading #2: ________________________

Pediatric Clinical Pulmonary Infection Score (Pediatric CPIS)

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Scoring for the Diagnosis of VAP

33
 Study Population Characteristics of Mechanically Ventilated Patients

DEMOGRAPHICS Intubation Characteristics Other Potential Risk Factors

Patient # Age Gender Admitting Route of Ventilation Re- Use of a Use of Nutrition Procedures Underlying
Diagnosis mechanical tube intubation device medications method pulmonary
ventilation characteristics or cardiac
disease

Cultures Hospital Outcome

Patient # TACS growth Blood Culture Other Culture VAP Ventilator Ventilator-free PICU Length Hospital Disposition
Growth Growth Days days of Stay

Death Home Others

34