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Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 145-148

Efficacy of modified ventilator-associated pneumonia prevention bundles on ventilator-associated pneumonia incidence rate in the intensive care unit: A pilot study

Nursing Supervisor, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India

Date of Submission04-Jul-2021
Date of Decision08-Dec-2022
Date of Acceptance13-Dec-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Mr. A Yuvaraj
5/404, Kamaraj Nagar, Veppadai, Elanthakuttai, Namakkal, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcn.ijcn_57_21

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Ventilator-associated pneumonia (VAP) is defined as pneumonia that develops in an intubated patient after 48 h of mechanical ventilation. In India, there is a paucity of literature in terms of compliance to VAP prevention bundles and their benefits. The aim of this study was to compare the reduction of VAP incidence rates amongst patients who received existing VAP prevention bundles and modified VAP prevention bundles. This pilot study was conducted in the adult intensive care unit of a tertiary care hospital. There were 60 patients in all, 30 patients in each group. The diagnosis of VAP was based on the clinical presentation and correlation with Clinical Pulmonary Infection Score. The incidence of VAP was 3/435 ventilator days (6.80%) in the patients receiving a modified VAP prevention bundle. In the conventional VAP prevention bundle group, the incidence of VAP was six episodes per 439 ventilator days (13.60%). Our study concluded that the modified VAP prevention bundle is effective in reducing the incidence of VAP amongst intubated patients.

Keywords: Clinical pulmonary infection score, intensive care units, ventilator-associated pneumonia prevention bundle, ventilator-associated pneumonia

How to cite this article:
Yuvaraj A. Efficacy of modified ventilator-associated pneumonia prevention bundles on ventilator-associated pneumonia incidence rate in the intensive care unit: A pilot study. Indian J Cont Nsg Edn 2022;23:145-8

How to cite this URL:
Yuvaraj A. Efficacy of modified ventilator-associated pneumonia prevention bundles on ventilator-associated pneumonia incidence rate in the intensive care unit: A pilot study. Indian J Cont Nsg Edn [serial online] 2022 [cited 2023 May 31];23:145-8. Available from: https://www.ijcne.org/text.asp?2022/23/2/145/366607

  Introduction Top

The patients rely on health care professionals for their recovery. The intensive care team is completely responsible to meet the patient's needs and preventing complications but unfortunately, complications occurred by the equipment/devices. Ventilator-associated pneumonia (VAP) is one of the complications of mechanical ventilation.

VAP is defined as pneumonia that develops in an intubated patient after 48 h of mechanical ventilation. VAP usually occurs due to aspiration, which is the primary route of transmission of pathogens into the lungs. Factors causing aspiration are a collection of oropharyngeal secretions, aspiration of gastric fluids or enteral feeding due to regurgitation/reflux. At times, patients admitted to the intensive care unit (ICU) already have bacterial colonisation. In addition, cross-infection in ICU is also one of the major causes of VAP. The incidence of nosocomial infection is higher in ICUs than in the wards. VAP is the most serious hospital-acquired infection and it is reported as the leading cause of morbidity and mortality in the ICU. It increases the cost of treatment, length of hospital stays and ICU stays and duration of mechanical ventilation in the affected patients.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11]

Expert groups such as the International Nosocomial Infection Control Consortium (INICC) and the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America have published practice recommendations to prevent VAP. Implementation of such recommendations has shown improved patient outcomes and proved to be cost-effective.[12],[13]

Recently, there have been reports of resistant organisms which proved prevention and treatment of nosocomial infections to be difficult. INICC conducted a study in 10 developing countries in 2012 and reported resistance of Staphylococcus aureus isolates to methicillin, enterobacteria resistant to ceftazidime (extended-spectrum beta-lactamase producers) and Pseudomonas aeruginosa resistant to fluoroquinolones.[1]

Within this context of antibiotic resistance, it is crucial to plan appropriate interventions to reduce the incidence of VAP. Hence, the protocol to prevent pneumonia can be formulated with special consideration of the particular unit. Innovative interventions are essential to prevent VAP infections and also to reduce the cost, workforce and material resources. Proper hand hygiene, oral hygiene, frequent oral suctioning, proper cuff pressure monitoring, continuous subglottic suction drainage and head-end elevation are important to prevent the colonisation of microorganisms in an oral cavity and appropriate use of antibiotics is recommended to prevent the VAP infection.


Our study aimed to compare the reduction of VAP incidence rates amongst patients who received existing VAP prevention bundles and modified VAP prevention bundles.

  Methods Top

This was a prospective study conducted in the adult ICU of a tertiary care hospital at Coimbatore, Tamil Nadu, India. Patients, who were intubated orally and mechanically ventilated, in the medical, trauma and surgical ICU, were included in this study. Patients receiving mechanical ventilation for more than 48 h between 18 and 80 years were included in the study. Patients having Clinical Pulmonary Infection Score (CPIS) >6 within 48 h of intubation, hospital and terminally ill patients were excluded from the study.


The final sample was size 60 patients randomly allocated to two groups: 30 patients to the intervention group and 30 to the control group. At the end of 48 h of intubation, the patients were evaluated using the CPIS, a score <6 was considered a cutoff for this study. If a patient had CPIS more than six within 48 h of intubation, was considered to have community-acquired pneumonia, and was not included in the study.

The primary outcome was the incidence of VAP. The secondary outcomes were duration of mechanical ventilation, days of ICU stay, reintubation rate, length of hospital stay, use of non-invasive ventilation (NIV), outcomes and number of days before the onset of VAP.


Modified CPIS: CPIS is a standardised tool, developed by Luna et al. (2003)[14] [Table 1]. It is widely used in clinical research and in infection control audits.[5],[6] Its reliability is reported to be, r = 0.96.[15] The CPIS had a specificity and positive predictive value of 100%.[16]
Table 1: Modified Clinical Pulmonary Infection Score

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The score ranges from 0 to 12. Score of more than 6 indicates possible of VAP provided for the control group.

Procedure for data collection

Before the data collection, necessary permission was obtained from the concerned authorities and formal information was given to nurses in charge of the surgical and medical ICUs. The study was conducted for a period of 8 weeks. Ethical clearance was obtained from the institutional ethical committee. Informed consent was obtained from the closest relatives of the study participants.

Subjects were randomly allocated to the intervention or control groups. The modified VAP prevention bundle care was provided to the interventional group while the control group received the conventional VAP prevention bundle care. 2-h teaching (lecturer and hands-on training) sections on evidence-based guidelines for VAP prevention were conducted for nurses who are giving care to the modified VAP prevention bundle group. Pre-test and post-test were conducted to assess the knowledge. The researcher supervised the nurses who delivered the care and implementation.

During the period of mechanical ventilation, patients in the study were constantly monitored for VAP, and CPIS was used to assess the presence and severity of infection. CPIS score enabled the researcher to objectively identify patients who developed VAP. Patients in the experimental group received a modified VAP prevention bundle and a conventional VAP prevention bundle was provided for the control group [Table 2]. Content validity was obtained for a modified VAP prevention bundle from the field of nursing, intensivist, epidemiologist, infection control committee, microbiologist, pulmonologist, respiratory therapist and statistician.
Table 2: Description of the interventions

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Statistical analysis

SPSS version 20 was employed for analysis (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Data were presented as a mean difference with standard deviation and with a 95% confidence interval. A Chi-square test was performed to compare the outcomes between the interventional and control groups. P < 0.05 is considered statistically significant.

  Results Top

Distribution of subjects according to demographic variables

Sixty percentage of patients were 18–25 years of age, 20% were 46–60 years and 20% were 61–80 years in the interventional group. In the control group, 50% were aged 18–25 years, 30% were aged 46–60 years and 20% were aged 61–80 years. Sixty percentage were males and 40% were females in the interventional group, and 70% were males and 20% were females in the control group.

Distribution of subjects according to clinical variables

Patients in the intervention group were admitted for trauma (30%), poisoning (30%), neurologic disorders (20%), respiratory disorders (9%) and other conditions (11%). In the control group, 30% were cases of trauma, 20% had neurologic disorders, 20% had poisoned, 10% had cardiovascular disease, respiratory disorders (10%) and 10% had other conditions. Sixty percentage of the patients in the intervention group and 40% in the control group were intubated for airway protection.

According to the ICU stay duration, most patients stayed 8–14 days in ICU in both the experimental groups (54.29%) and in the control group (62.86%). In the experimental group, 3.81% of patients and 9.52% of patients in the control group stayed 4–7 days extra than no VAP patients. With regard to the duration of hospital stay, most patients (52.38% and 68.57%) stayed 15–21 days in the experimental and control groups, respectively. The hospital stay was prolonged to significantly more number of patients in the control group compared to the experimental group.

Comparison of occurrence of ventilator-associated pneumonia

The incidence of VAP was three episodes per 435 ventilator days (6.80%) in the modified VAP prevention bundle group. In the conventional VAP prevention bundle group, the incidence of VAP was nine episodes per 439 ventilator days (13.60%). The incidence rate was calculated for 1000 ventilator days. It was 6.9 in the experimental group and 20.5 in the control group. A simple prevalence calculation showed 10% (3/30) of patients in the experimental group and 30% (9/30) in the control group had VAP infection. There was a statistically significant difference in the presence of VAP between both groups, with a P = 0.02 [Table 3]. This indicates that the modified VAP prevention bundle was effective in reducing the occurrence of VAP amongst intubated patients.
Table 3: Comparison of occurrence of ventilatorassociated pneumonia amongst intubated subjects in intervention and control groups (n=60)

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  Discussion Top

The study concluded that there was a significant reduction in the occurrence of VAP in the modified VAP prevention bundle group than in the control group. These interventions seemed to reduce the VAP rate effectively. The VAP rates of 10% and 30% were similar to previous studies. The incidence rate in the experimental group (6.9) is much lower than the previous studies showing the worth of using the modified bundle.[1],[4] There is strong evidence through a systematic review that VAP is associated with longer hospital stays and increased mortality.[1] Arabi et al. conducted an international review of VAP in adults; from 1966 to 2007 and reported that the VAP rates were 10–41.7/1000 ventilator days. They found that the crude mortality rates were 16%–94%. ICU Extra length of stay increases more than 7 days and increases the risk of death by 14%. Eighty-six percentage of nosocomial pneumonia was associated with intubation and mechanical ventilation.[1] The reduction in the number of people staying in the hospital for additional 4–7 days in the experimental group compared to the control group in this study, further emphasises that those who had infection in the experimental group also had better outcomes. NIV usage, regular oral care, proper hand hygiene, proper cuff pressure and subglottic suctioning that were included in the modified procedure reduced VAP in the experimental study. Betadine that was used in the control group has already been shown to have no difference on VAP in a previous study[17] and the change to chlorhexidine mouth has shown considerable effect in reducing VAP.[4] Therefore, modifying protocol based on earlier evidence has reiterated the use of this medication in reducing VAP.

Limitations: This was a single-centre study and the sample size was small and therefore generalisation is limited. The age range of 18–80 years also could have influenced the findings as older persons may have reduced immunity against infections.

  Conclusion Top

This study concluded that the modified VAP prevention bundle is effective in reducing the incidence of VAP amongst intubated patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Arabi Y, Al-Shirawi N, Memish Z, Anzueto A. Ventilator-associated pneumonia in adults in developing countries: A systematic review. Int J Infect Dis 2008;12:505-12.  Back to cited text no. 1
Black JM, Hawks JH, Keene AM. Clinical management for positive outcomes. In: Medical – Surgical Nursing. 7th ed. St. Louis: Saunders Elsevier; 2009. p. 227-80.  Back to cited text no. 2
Burns N, Grove SK. Understanding Nursing Research eBook: Building an Evidence Based Practice. US: Elsevier Health Sciences; 2010.  Back to cited text no. 3
de Lacerda Vidal CF, Vidal AK, Monteiro JG Jr., Cavalcanti A, Henriques AP, Oliveira M, et al. Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: A randomized study. BMC Infect Dis 2017;17:112.  Back to cited text no. 4
Güler E, Kahveci F, Akalın H, Sınırtaş M, Bayram S, Özcan B. Evaluation of a clinical pulmonary infection score in the diagnosis of ventilator associated pneumonia. Signa Vitae 2012;7:32-7.  Back to cited text no. 5
Mohanty D, Routray SS, Mishra D, Das A. Ventilator associated pneumonia in a ICU of a tertiary care hospital in India. IJCMR 2016;3:1046-9.  Back to cited text no. 6
Dumbre DU. A study to assess the knowledge and compliance of critical care nurses regarding ventilator care bundle in prevention of ventilator associated pneumonia. Med Legal Update 2019;19:176-8.  Back to cited text no. 7
Hassan ZM, Wahsheh MA. Knowledge level of nurses in Jordan on ventilator-associated pneumonia and preventive measures. Nurs Crit Care 2017;22:125-32.  Back to cited text no. 8
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Lewis SM, Dirksen SR, Heitkemper MM, Bucher L, Harding M. Medical Surgical Nursing: Assessment and Management of Clinical Problems. 7th ed. Missouri: Mosby; 2003.  Back to cited text no. 10
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Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:915-36.  Back to cited text no. 12
The International Nosocomial Infection Control Consortium (INICC); 2012. Available from www.INICC.org. [Last accessed on 2022 Apr 20].  Back to cited text no. 13
Luna CM, Blanzaco D, Niederman MS, Matarucco W, Baredes NC, Desmery P, et al. Resolution of ventilator-associated pneumonia: prospective evaluation of the clinical pulmonary infection score as an early clinical predictor of outcome. Crit Care Med 2003;31:676-82.  Back to cited text no. 14
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Eckert MJ, Davis KA, Reed RL 2nd, Esposito TJ, Santaniello JM, Poulakidas S, et al. Ventilator-associated pneumonia, like real estate: Location really matters. J Trauma 2006;60:104-10.  Back to cited text no. 16
Seguin P, Laviolle B, Dahyot-Fizelier C, Dumont R, Veber B, Gergaud S, et al. Effect of oropharyngeal povidone-iodine preventive oral care on ventilator-associated pneumonia in severely brain-injured or cerebral hemorrhage patients: A multicenter, randomized controlled trial. Crit Care Med 2014;42:1-8.  Back to cited text no. 17


  [Table 1], [Table 2], [Table 3]


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