VAP Rates Unchanged

In a research letter to JAMA Metersky and colleagues (1) report that ventilator-associated pneumonia (VAP) rates have remained near 10% since 2005. The authors reviewed Medicare Patient Safety Monitoring System (MPSMS) data on a representative sample of more than 86,000 critically ill patients treated at 1330 US hospitals between 2005 and 2013. To meet a diagnosis of VAP patients were required to have at least 2 days' ventilation in intensive care units; a chest radiograph with a new finding suggesting pneumonia; a physician diagnosis of pneumonia; and an order for antibiotics. VAP incidence was 10.8% (95% confidence interval, 7.4% - 14.4%) during 2005 to 2006 and 9.7% (95% confidence interval, 5.1% - 14.9%) during 2012 to 2013.

In contrast, data from the CDC's National Healthcare Safety Network (NHSN) have shown declines in VAP rates of 71% and 62% in medical and surgical intensive care units, respectively, between 2006 and 2012 (2,3). "The most likely explanation for the discrepancy is thought to be bias in reporting to CDC by the hospitals," Dr. Metersky told Medscape Medical News (4). Dr. Charles S. Dela Cruz at Yale agrees. "Strict and varying VAP measure definitions and the hospital reporting mechanisms possibly contributed to the differences in rates," he said.

VAP has no standard definition and its diagnosis has considerable clinical variability. Other than removing the endotracheal tube as quickly as possible, VAP prevention guidelines are non- or weakly evidence-based (5). Furthermore, financial incentives from CMS for low VAP rates may have contributed to the bias in reporting (6).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Metersky ML, Wang Y, Klompas M, Eckenrode S, Bakullari A, Eldridge N. Trend in ventilator-associated pneumonia rates between 2005 and 2013. JAMA. 2016 Nov 11. [Epub ahead of print] [CrossRef] [PubMed]
2. Edwards JR, Peterson KD, Andrus ML, et al; NHSN Facilities. National Healthcare Safety Network (NHSN) Report, data summary for 2006, issued June 2007. Am J Infect Control. 2007;35(5):290-301. [CrossRef] [PubMed]
3. Dudeck MA, Weiner LM, Allen-Bridson K, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, device-associated module. Am J Infect Control. 2013;41(12):1148-66. [CrossRef] [PubMed]
4. Swift D. No drop in VAP rates, study contends. Medscape Medical News. November 21, 2016. Available at: http://www.medscape.com/viewarticle/872157?nlid=110853_3464&src=WNL_mdplsfeat_161129_mscpedit_ccmd&uac=9273DT&spon=32&impID=1243721&faf=1 (accessed 12/2/16).
5. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
6. Cassidy A. Medicare's hospital-acquired condition reduction program. Health Affairs. August 6, 2015. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=142  (accessed 12/2/16).

Cite as: Robbins RA. VAP rates unchanged. Southwest J Pulm Crit Care. 2016;13(6):288-9. doi: https://doi.org/10.13175/swjpcc134-16 PDF

Dental Visits May Prevent Pneumonia

Several sources are reporting on a paper presented at IDWeek that showed people with a regular dental checkup had half the incidence of bacterial pneumonia (1). Michelle Doll and colleagues used the Medical Expenditure Panel Survey (MEPS) data from 2013. The researchers were able to assess participants' access to dental care and used ICD-9 codes to look for bacterial pneumonia in the previous year. The survey had data on 26,687 people, including 441 who had an episode of bacterial pneumonia. Thirty-four percent of those who developed pneumonia reported having at least two dental checkups a year, compared with 46% of those who did not. It is important to point out that this is an observational study and there were significant differences between those who developed and did not develop bacterial pneumonia. Those who got pneumonia were: more likely to be white and older, with an average age of 47 versus 40; more likely to have comorbidities and cognitive limitations; and less likely to have dental insurance.

Nevertheless, the data is consistent with the hypothesis that microaspiration is a frequent cause of bacterial pneumonia. Previous data has shown oral chlorhexidine reduces ventilator-associated pneumonia in the ICU (2). Although a large randomized study is needed, the data suggests that dental care may be another community-acquired pneumonia preventative in addition to conjugated pneumococcal vaccine (3).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Smith M. Regular checkups linked to protection against bacterial disease. Medscape. October 28, 2016. Available at: http://www.medpagetoday.com/MeetingCoverage/IDWeek/61071 (accessed 10/28/16). 
2. Hua F, Xie H, Worthington HV, Furness S, Zhang Q, Li C. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2016 Oct 25;10:CD008367. [CrossRef] [PubMed]
3. Bonten MJ, Huijts SM, Bolkenbaas M, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med. 2015 Mar 19;372(12):1114-25. [CrossRef] [PubMed]

Cite as: Robbins RA. Dental visits may prevent penumonia. Southwest J Pulm Crit Care. 2016;13(4):186. doi: http://dx.doi.org/10.13175/swjpcc105-16 PDF