Guidelines of Prevention of Ventilator Associated Pneumonia

Prevention of Health-Care--Associated Bacterial Pneumonia
I. Staff Education and Involvement in Infection Prevention
Educate health-care workers about the epidemiology of, and infection-control procedures for, preventing health-care--associated bacterial pneumonia to ensure worker competency according to the worker's level of responsibility in the health-care setting, and involve the workers in the implementation of interventions to prevent health-care--associated pneumonia by using performance-improvement tools and techniques (IA).
II. Infection and Microbiologic Surveillance

A. Conduct surveillance for bacterial pneumonia in intensive care unit (ICU) patients who are at high risk for health-care--related bacterial pneumonia (e.g., patients with mechanically assisted ventilation or selected postoperative patients) to determine trends and help identify outbreaks and other potential infection-control problems.The use of the new National Nosocomial Infection Surveillance (NNIS) system's surveillance definition of pneumonia is recommended. Include data on the causative microorganisms and their antimicrobial susceptibility patterns. Express data as rates (e.g., number of infected patients or infections per 100 ICU days or per 1,000 ventilator days) to facilitate intrahospital comparisons and trend determination.
B. In the absence of specific clinical, epidemiologic, or infection-control objectives, do not routinely perform surveillance cultures of patients or of equipment or devices used for respiratory therapy, pulmonary-function testing, or delivery of inhalation anesthesia (II).
III. Prevention of Transmission of Microorganisms
A. Sterilization or Disinfection and Maintenance of Equipment and Devices
1. General measures
a. Thoroughly clean all equipment and devices to be sterilized or disinfected (IA).
b. Whenever possible, use steam sterilization (by autoclaving) or high-level disinfection by wet heat pasteurization at >158 F (>70°C) for 30 minutes for reprocessing semicritical equipment or devices (i.e., items that come into direct or indirect contact with mucous membranes of the lower respiratory tract) that are not sensitive to heat and moisture. Use low-temperature sterilization methods (as approved by the Office of Device Evaluation, Center for Devices and Radiologic Health, Food and Drug Administration [FDA]) for equipment or devices that are heat- or moisture-sensitive. After disinfection, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items in the process (IA).
c. Preferentially use sterile water for rinsing reusable semicritical respiratory equipment and devices when rinsing is needed after they have been chemically disinfected. If this is not feasible, rinse the device with filtered water (i.e., water that has been through a 0.2µ filter) or tap water, and then rinse with isopropyl alcohol and dry with forced air or in a drying cabinet (IB).
d. Single-use devices that are reprocessed by third parties (IC).

2. Mechanical ventilators

Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators (II).

3. Breathing circuits, humidifiers, and heat-and-moisture exchangers (HMEs)

a. Breathing circuits with humidifiers

1) Do not change routinely, on the basis of duration of use, the breathing circuit (i.e., ventilator tubing and exhalation valve and the attached humidifier) that is in use on an individual patient. Change the circuit when it is visibly soiled or mechanically malfunctioning (IA).

2) Breathing-circuit--tubing condensate

a) Periodically drain and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward the patient (IB).
b) Wear gloves to perform the previous procedure and/or when handling the fluid (IB).
c) Decontaminate hands with soap and water (if hands are visibly soiled) or with an alcohol-based hand rub after performing the procedure or handling the fluid (IA).
3) No recommendation can be made for placing a filter or trap at the distal end of the expiratory-phase tubing of the breathing circuit to collect condensate (Unresolved issue).

4) Humidifier fluids

a) Use sterile (not distilled, nonsterile) water to fill bubbling humidifiers (II).
b) No recommendation can be made for the preferential use of a closed, continuous-feed humidification system (Unresolved issue).

b. Ventilator breathing circuits with HMEs

1) No recommendation can be made for the preferential use of either HMEs or heated humidifiers to prevent pneumonia in patients receiving mechanically assisted ventilation (Unresolved issue) (IB).

2) Changing HME

a) Change an HME that is in use on a patient when it malfunctions mechanically or becomes visibly soiled (II).
b) Do not routinely change more frequently than every 48 hours an HME that is in use on a patient (II).
3) Do not change routinely (in the absence of gross contamination or malfunction) the breathing circuit attached to an HME while it is in use on a patient (II).

4. Oxygen humidifiers

a. Follow manufacturers' instructions for use of oxygen humidifiers (II,C).
b. Change the humidifier-tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated (II).

5. Small-volume medication nebulizers: in-line and hand-held nebulizers

a. Between treatments on the same patient clean, disinfect, rinse with sterile water (if rinsing is needed), and dry small-volume in-line or hand-held medication nebulizers (IB).
b. Use only sterile fluid for nebulization, and dispense the fluid into the nebulizer aseptically (IA).
c. Whenever possible, use aerosolized medications in single-dose vials. If multidose medication vials are used, follow manufacturers' instructions for handling, storing, and dispensing the medications (IB).

6. Mist tents

a. Between uses on different patients, replace mist tents and their nebulizers, reservoirs, and tubings with those that have been subjected to sterilization or high-level disinfection (II).
b. No recommendation can be made about the frequency of routinely changing mist-tent nebulizers, reservoirs, and tubings while in use on one patient (Unresolved issue).
c. Subject mist-tent nebulizers, reservoirs, and tubings that are used on the same patient to daily low-level disinfection (e.g., with 2% acetic acid) or pasteurization followed by air-drying (II).

7. Other devices used in association with respiratory therapy

a. Respirometer and ventilator thermometer: between their uses on different patients, sterilize or subject to high-level disinfection portable respirometers and ventilator thermometers (IB).

b. Resuscitation bags

1) Between their uses on different patients, sterilize or subject to high-level disinfection reusable hand-powered resuscitation bags (IB).
2) No recommendation can be made about the frequency of changing hydrophobic filters placed on the connection port of resuscitation bags (Unresolved issue).

8. Anesthesia machines and breathing systems or patient circuits

a. Do not routinely sterilize or disinfect the internal machinery of anesthesia equipment (IB).
b. Between uses on different patients, clean reusable components of the breathing system or patient circuit (e.g., tracheal tube or face mask) inspiratory and expiratory breathing tubing, y-piece, reservoir bag, humidifier, and tubing, and then sterilize or subject them to high-level liquid chemical disinfection or pasteurization in accordance with the device manufacturers' instructions for their reprocessing (IB).
c. No recommendation can be made about the frequency of routinely cleaning and disinfecting unidirectional valves and carbon dioxide absorber chambers (Unresolved issue).
d. Follow published guidelines or manufacturers' instructions about in-use maintenance, cleaning, and disinfection or sterilization of other components or attachments of the breathing system or patient circuit of anesthesia equipment (IB).
e. No recommendation can be made for placing a bacterial filter in the breathing system or patient circuit of anesthesia equipment (Unresolved issue).

9. Pulmonary-function testing equipment

a. Do not routinely sterilize or disinfect the internal machinery of pulmonary-function testing machines between uses on different patients (II).
b. Change the mouthpiece of a peak flow meter or the mouthpiece and filter of a spirometer between uses on different patients (II).

10. Room-air "humidifiers" and faucet aerators

a. Do not use large-volume room-air humidifiers that create aerosols (e.g., by venturi principle, ultrasound, or spinning disk, and thus actually are nebulizers) unless they can be sterilized or subjected to high-level disinfection at least daily and filled only with sterile water (II).
b. Faucet aerators

1) No recommendation can be made about the removal of faucet aerators from areas for immunocompetent patients (see also section on Legionnaires Disease, Part II, Section I-C-1-d) (Unresolved issue).
2) If Legionella spp. are detected in the water of a transplant unit and until Legionella spp. are no longer detected by culture, remove faucet aerators in the unit (see also section on Legionnaires Disease, Part II, Section I-C-1-d) (II).

B. Prevention of Person-to-Person Transmission of Bacteria

1. Standard Precautions

a. Hand hygiene: Decontaminate hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water (if hands are visibly dirty or contaminated with proteinaceous material or are soiled with blood or body fluids) or by using an alcohol-based waterless antiseptic agent (e.g., hand rub) if hands are not visibly soiled after contact with mucous membranes, respiratory secretions, or objects contaminated with respiratory secretions, whether or not gloves are worn. Decontaminate hands as described previously before and after contact with a patient who has an endotracheal or tracheostomy tube in place, and before and after contact with any respiratory device that is used on the patient, whether or not gloves are worn (IA).

b. Gloving

1) Wear gloves for handling respiratory secretions or objects contaminated with respiratory secretions of any patient (IB).
2) Change gloves and decontaminate hands as described previously between contacts with different patients; after handling respiratory secretions or objects contaminated with secretions from one patient and before contact with another patient, object, or environmental surface; and between contacts with a contaminated body site and the respiratory tract of, or respiratory device on, the same patient (IA).
c. When soiling with respiratory secretions from a patient is anticipated, wear a gown and change it after soiling occurs and before providing care to another patient (IB).

2. Care of patients with tracheostomy

a. Perform tracheostomy under aseptic conditions (II).
b. When changing a tracheostomy tube, wear a gown, use aseptic technique, and replace the tube with one that has undergone sterilization or high-level disinfection (IB).
c. No recommendation can be made for the daily application of topical antimicrobial agent(s) at the tracheostoma (Unresolved issue).

3. Suctioning of respiratory tract secretions

a. No recommendation can be made for the preferential use of either the multiuse closed-system suction catheter or the single-use open-system suction catheter for prevention of pneumonia (Unresolved issue).
b. No recommendation can be made about wearing sterile rather than clean gloves when performing endotracheal suctioning (Unresolved issue).
c. No recommendation can be made about the frequency of routinely changing the in-line suction catheter of a closed-suction system in use on one patient (Unresolved issue).
d. If the open-system suction is employed, use a sterile, single-use catheter (II).
e. Use only sterile fluid to remove secretions from the suction catheter if the catheter is to be used for re-entry into the patient's lower respiratory tract (II).
IV. Modifying Host Risk for Infection
A. Increasing Host Defense against Infection: Administration of immune modulators
1. Pneumococcal vaccination.
Vaccinate patients at high risk for severe pneumococcal infections
a. Administer the 23-valent pneumococcal polysaccharide vaccine to persons aged >65 years; persons aged 5--64 years who have chronic cardiovascular disease (e.g., congestive heart failure or cardiomyopathy), chronic pulmonary disease (e.g., chronic obstructive pulmonary disease [COPD] or ermphysema, but not asthma), diabetes mellitus, alcoholism, chronic liver disease (e.g., cirrhosis), or cerebrospinal fluid (CSF) leaks; persons aged 5--64 years who have functional or anatomic asplenia; persons aged 5--64 years who are living in special environments or social settings; immunocompromised persons aged >5 years with HIV infection, leukemia, lymphoma, Hodgkin's disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression (e.g., receipt of HSCT, solid-organ transplant, or immunosuppressive chemotherapy, including long-term systemic corticosteroids); and persons in long-term--care facilities (IA).
b. Administer the 7-valent pneumococcal polysaccharide protein-conjugate vaccine to all children aged <2 years and to children aged 24--59 months who are at increased risk for pneumococcal disease (e.g., children with sickle-cell disease or other hemoglobinopathies, or children who are functionally or anatomically asplenic; children with HIV infection; children who have chronic disease, including chronic cardiac or pulmonary disease [except asthma], diabetes mellitus, or CSF leak; and children with immunocompromising conditions including malignancies, chronic renal failure or nephrotic syndrome, receipt of immunosuppressive chemotherapy, including long-term corticosteroids, and receipt of solid-organ transplant). Consider administering the vaccine to children aged 24--59 months, with priority to children aged 24--35 months, children who are American Indians/Alaska Natives or black, and children who attend group child care centers (IB).
c. In nursing homes and other long-term--care facilities, establish a standing order program (SOP) for the administration of 23-valent vaccine to persons at high risk for acquiring severe pneumococcal infections, including pneumococcal pneumonia (IA).
2. No recommendation can be made for the routine administration of preparations of granulocyte-colony stimulating factor (GCSF) or intravenous gamma globulin for prophylaxis against health-care--associated pneumonia (Unresolved issue).
3. No recommendation can be made for the routine enteral administration of glutamine for prevention of health-care--associated pneumonia (Unresolved issue).