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Year : 2017  |  Volume : 145  |  Issue : 5  |  Page : 697-698

Evaluating rates of ventilator-associated pneumonia: Consider patient, organizational & educational risk factors

1 Burns Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, Australia
2 Intensive Care Unit, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
3 Department of Internal Medicine, Ghent University, Ghent, Belgium

Date of Submission13-Mar-2017
Date of Web Publication25-Sep-2017

Correspondence Address:
Stijn Blot
Department of Internal Medicine, Ghent University, Ghent
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmr.IJMR_435_17

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How to cite this article:
Koulenti D, Boulanger C, Blot S. Evaluating rates of ventilator-associated pneumonia: Consider patient, organizational & educational risk factors. Indian J Med Res 2017;145:697-8

How to cite this URL:
Koulenti D, Boulanger C, Blot S. Evaluating rates of ventilator-associated pneumonia: Consider patient, organizational & educational risk factors. Indian J Med Res [serial online] 2017 [cited 2021 Sep 25];145:697-8. Available from:


We read with interest the research article by Chaudhury et al[1] reporting on rates of ventilator-associated pneumonia (VAP) and associated multidrug resistance (MDR) patterns in a tertiary care hospital in India. VAP remains an important cause of critical illness-related morbidity and results as such in an important economic burden [2],[3]. While VAP is associated with substantial mortality, the attributable fraction of the death toll remains a matter of controversy [4]; for sure, the final impact of this infectious complication is multifactorial encompassing patient risk factors such as older age, immune status and other comorbidities as well as adequacy of intensive care management [5],[6]. The latter includes aspects of organ support and efforts to optimize antimicrobial therapy. MDR involvement is an important factor complicating the infection [7],[8]. MDR decreases the likelihood of appropriate empiric coverage of the assumed causative pathogens [9],[10], and further complicates adequate dosing, which is already a challenge in critically ill patients [11].

The work reported by Chaudhury et al[1] is important because detailed insights in microbial ecology, either on unit level or individual patient level, is important to steer empiric antibiotic therapy [12],[13]. We have however, some comments on the reported data. First, over the three year study (2011-2013) the authors report a substantial number (n=63) of Candida species considered pneumonia pathogens [1]. While respiratory tract colonization with Candida species is common in mechanically ventilated patients, true Candida pneumonia is considered to be extremely rare [14],[15],[16]. In addition, the diagnosis of Candida pneumonia is challenging as it requires histological sampling to demonstrate tissue invasion. Therefore, we wonder on what basis the authors discriminated Candida colonization from Candida pneumonia. Second, the rates of VAP reported are although high, yet no data are provided on patients' profile. That is a pity as infection rates cannot be fairly judged in the absence of case mix data. Furthermore, to evaluate any trends in VAP rates, shifts in case mix (i.e., risk profile for infection) should be considered. Finally, VAP rates also depend on organizational factors such as the nurse-to-patient ratio. An acceptable workload is conditional to achieve high compliance rates with infection prevention measures. For example, excessive workload is a main obstacle to adhere with general recommendations in hand hygiene, a cornerstone in infection prevention. An additional issue is the educational level of staff members and the nursing team in particular. Significant gaps in knowledge regarding VAP prevention have been demonstrated before, and modern educational formats have been developed to these gaps [17],[18]. More important however, is the overall background of the intensive care nurses. One cannot build high levels of specific insights when a solid overall base of critical care nursing is lacking. A survey indicated huge differences in critical care nursing education in European countries [19]. This survey was a clear call to join forces in the development of an international critical care nursing curriculum. As the last question to the authors of this study [1], we wonder if a specialized critical care nursing education exists in India and how it is organized.

Conflicts of Interest: None.

   References Top

Chaudhury A, Rani AS, Kalawat U, Sumant S, Verma A, Venkataramana B. Antibiotic resistance & pathogen profile in ventilator-associated pneumonia in a tertiary care hospital in India. Indian J Med Res 2016; 144 : 440-6.  Back to cited text no. 1
Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: A systematic review. Crit Care Med 2005; 33 : 2184-93.  Back to cited text no. 2
Myny D, Depuydt P, Colardyn F, Blot S. Ventilator-associated pneumonia in a tertiary care ICU: Analysis of risk factors for acquisition and mortality. Acta Clin Belg 2005; 60 : 114-21.  Back to cited text no. 3
Timsit JF, Zahar JR, Chevret S. Attributable mortality of ventilator-associated pneumonia. Curr Opin Crit Care 2011; 17 : 464-71.  Back to cited text no. 4
Blot S, Koulenti D, Dimopoulos G, Martin C, Komnos A, Krueger WA, et al. Prevalence, risk factors, and mortality for ventilator-associated pneumonia in middle-aged, old, and very old critically ill patients*. Crit Care Med 2014; 42 : 601-9.  Back to cited text no. 5
Koulenti D, Blot S, Dulhunty JM, Papazian L, Martin-Loeches I, Dimopoulos G, et al. COPD patients with ventilator-associated pneumonia: Implications for management. Eur J Clin Microbiol Infect Dis 2015; 34 : 2403-11.  Back to cited text no. 6
Blot S. Limiting the attributable mortality of nosocomial infection and multidrug resistance in Intensive Care Units. Clin Microbiol Infect 2008; 14 : 5-13.  Back to cited text no. 7
Agbaht K, Diaz E, Muñoz E, Lisboa T, Gomez F, Depuydt PO, et al. Bacteremia in patients with ventilator-associated pneumonia is associated with increased mortality: A study comparing bacteremic vs. nonbacteremic ventilator-associated pneumonia. Crit Care Med 2007; 35 : 2064-70.  Back to cited text no. 8
Depuydt PO, Blot SI, Benoit DD, Claeys GW, Verschraegen GL, Vandewoude KH, et al. Antimicrobial resistance in nosocomial bloodstream infection associated with pneumonia and the value of systematic surveillance cultures in an adult Intensive Care Unit. Crit Care Med 2006; 34 : 653-9.  Back to cited text no. 9
Vogelaers D, De Bels D, Forêt F, Cran S, Gilbert E, Schoonheydt K, et al. Patterns of antimicrobial therapy in severe nosocomial infections: Empiric choices, proportion of appropriate therapy, and adaptation rates – A multicentre, observational survey in critically ill patients. Int J Antimicrob Agents 2010; 35 : 375-81.  Back to cited text no. 10
Blot SI, Pea F, Lipman J. The effect of pathophysiology on pharmacokinetics in the critically ill patient – Concepts appraised by the example of antimicrobial agents. Adv Drug Deliv Rev 2014; 77 : 3-11.  Back to cited text no. 11
Cotta MO, Roberts JA, Tabah A, Lipman J, Vogelaers D, Blot S. Antimicrobial stewardship of ß-lactams in Intensive Care Units. Expert Rev Anti Infect Ther 2014; 12 : 581-95.  Back to cited text no. 12
Brusselaers N, Labeau S, Vogelaers D, Blot S. Value of lower respiratory tract surveillance cultures to predict bacterial pathogens in ventilator-associated pneumonia: Systematic review and diagnostic test accuracy meta-analysis. Intensive Care Med 2013; 39 : 365-75.  Back to cited text no. 13
Blot S, Vandewoude K. Management of invasive candidiasis in critically ill patients. Drugs 2004; 64 : 2159-75.  Back to cited text no. 14
Terraneo S, Ferrer M, Martín-Loeches I, Esperatti M, Di Pasquale M, Giunta V, et al. Impact of Candida spp. isolation in the respiratory tract in patients with Intensive Care Unit-acquired pneumonia. Clin Microbiol Infect 2016; 22 : 94.e1-8.  Back to cited text no. 15
Meersseman W, Lagrou K, Spriet I, Maertens J, Verbeken E, Peetermans WE, et al. Significance of the isolation of Candida species from airway samples in critically ill patients: A prospective, autopsy study. Intensive Care Med 2009; 35 : 1526-31.  Back to cited text no. 16
Labeau S, Vandijck DM, Claes B, Van Aken P, Blot SI; Executive Board of the Flemish Society for Critical Care Nurses. Critical care nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: An evaluation questionnaire. Am J Crit Care 2007; 16 : 371-7.  Back to cited text no. 17
Labeau SO, Rello J, Dimopoulos G, Lipman J, Sarikaya A, Oztürk C, et al. The value of E-learning for the prevention of healthcare-associated infections. Infect Control Hosp Epidemiol 2016; 37 : 1052-9.  Back to cited text no. 18
Endacott R, Jones C, Bloomer MJ, Boulanger C, Ben Nun M, Lliopoulou KK, et al. The state of critical care nursing education in Europe: An international survey. Intensive Care Med 2015; 41 : 2237-40.  Back to cited text no. 19


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