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Krankenhaushygiene up2date 2012; 07(04): 275-289
DOI: 10.1055/s-0032-1325954
Nosokomiale Infektionen
© Georg Thieme Verlag KG Stuttgart · New York

Beatmungsassoziierte Pneumonie – was gibt es Neues?

Karl Lewalter
,
Sebastian Lemmen
,
Simone Scheithauer
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Publication History

Publication Date:
11 December 2012 (online)

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Kernaussagen

  • Die beatmungsassoziierte Pneumonie ist die häufigste nosokomiale Infektion auf Intensivstationen und von hoher medizinischer und ökonomischer Relevanz.

  • Als wesentlicher Pathomechanismus gilt die Mikroaspiration. Übersedierung, unnötige Beatmung und das Nichteinhalten krankenhaushygienischer Präventionsmaßnahmen sind die wesentlichen Ursachen für die BAP.

  • Zur Vermeidung der BAP stehen viele Interventionsmöglichkeiten mit unterschiedlicher Evidenz zur Verfügung.

  • Insbesondere die Einführung einiger ausgewählter, evidenzbasierter Maßnahmen als Bündel hat sich bewährt.

  • Unbedingt durchgeführt werden sollten: die Einführung von Sedierungsprotokollen nach S3-Leitlinie und eine strukturierte Entwöhnung von der Beatmung, z. B. über Weaning-Protokolle. Standardhygiene (Händedesinfektion!), kritische Indikationsstellung zur invasiven Beatmung, antiseptische Mundpflege, aktive Surveillance der eigenen BAP-Rate, regelmäßige Schulungen des Personals und die Oberkörperhochlagerung.

  • Bei trotz Ausschöpfung aller Basismaßnahmen persistierend hohen BAP-Raten kann der Einsatz weiterer Maßnahmen erwogen werden, wie z. B. die subglottische Sekretabsaugung oder SOD/SDD.

  • (Bislang) nicht hinreichend evidenzbasierte Maßnahmen sind: täglicher Wechsel der Beatmungsschläuche, Einsatz von Probiotika, Art der Ernährung, Zeitpunkt der Tracheotomie, Einsatz von kinetischen Betten.

  • Der Erfolg der Implementierung infektionspräventiver Maßnahmen sollte durch Teilnahme an Surveillanceprogrammen, wie z. B. KISS, evaluiert werden.

 

  • Literatur

  • 1 Safdar N, Crnich CJ, Maki D. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention. Resp Care 2005; 50: 725-741
    Google Scholar
  • 2 Pawar M, Mehta Y, Khurana P et al. Ventilator-associated pneumonia: incidence, risk factors, outcome and microbiology. J Cardiothorac Vasc Anesth 2003; 17: 22-28
    CrossrefGoogle Scholar
  • 3 Cook DJ, Walter SD, Cook RJ et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill adults. Ann Intern Med 1998; 129: 433-440
    CrossrefGoogle Scholar
  • 4 Klompas M. Does this patient have ventilator-associated pneumonia?. J Am Med Assoc 2007; 297: 1583-1593
    CrossrefGoogle Scholar
  • 5 Gastmeier P, Sohr D, Geffers C et al. Early- and late-onset pneumonia: is this still a useful classification?. Antimicrob Agents Chemother 2009; 53: 2714-2718
    CrossrefGoogle Scholar
  • 6 Tablan OC, Anderson LJ, Besser R et al. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healtcare Infection Control Practices Advisory Committee. MMWR Recomm 2004; 53: 1-36
    Google Scholar
  • 7 Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol 2012; 33: 250-256
    CrossrefGoogle Scholar
  • 8 Moller AH, Hansen L, Jensen MS et al. A cost-effectiveness analysis of reducing ventilator-associated pneumonia at a Danish ICU with ventilator bundle. J Med Econ 2012; 15: 285-292
    CrossrefGoogle Scholar
  • 9 Timsit JF, Zahar JR, Chevret S. Attributable mortality of ventilator-associated pneumonia. Curr Opin Crit Care 2011; 17: 464-471
    CrossrefGoogle Scholar
  • 10 Berwick DM, Calkins DR, McCannon CJ et al. The 100000 Lives Campaign. Setting a goal and a deadline for improving health care quality. J Am Med Assoc 2006; 295: 324-327
    CrossrefGoogle Scholar
  • 11 Girard TD, Kress JP, Fuchs BD et al. Efficacy and safety of a paired sedation and ventilator-weaning protocol for mechanically ventilated patients in intensive care: a randomized controlled trial. Lancet 2008; 371: 126-134
    CrossrefGoogle Scholar
  • 12 Zuschneid I, Schwab F, Geffers C et al. Trends in ventilator-associated pneumonia rates within the German Nosocomial Infection Surveillance System (KISS). Infect Control Hosp Epidemiol 2007; 28: 314-318
    CrossrefGoogle Scholar
  • 13 Salahuddin N, Zafar A, Sukhyani L et al. Reducing ventilator-associated pneumonia rates through a staff education programme. J Hosp Inf 2004; 57: 223-227
    CrossrefGoogle Scholar
  • 14 Ferrer R, Artigas A, Levy MM et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in spain. J Am Med Assoc 2008; 299: 2294-2303
    CrossrefGoogle Scholar
  • 15 World Health Organization (WHO). WHO Guidelines for Hand Hygiene in Health Care. Geneva: WHO; 2009
    Google Scholar
  • 16 Koff MD, Corwin HL, Beach ML et al. Reduction in ventilator associated pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program. J Crit Care 2011; 26: 489-495
    CrossrefGoogle Scholar
  • 17 Rewa O, Muscedere J. Ventilator-associated pneumonia: update on etiology, prevention and management. Curr Infect Dis Rep 2011; 13: 287-295
    CrossrefGoogle Scholar
  • 18 Brochard L. Mechanical ventilation: invasive versus noninvasive. Eur Respir J 2003; 22 : 31-37
    CrossrefGoogle Scholar
  • 19 Drakulovic M, Torres A, Bauer TT et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet 1999; 354: 1851-1858
    CrossrefPubMedGoogle Scholar
  • 20 Van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Thiel FH et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006; 34: 396-402
    CrossrefGoogle Scholar
  • 21 Niel-Weise BS, Gastmeier P, Kola A et al. An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Crit Care 2011; 15: R111
    CrossrefGoogle Scholar
  • 22 Craven DE, Lichtenberg DA, Goularte TA et al. Contaminated medication nebulizers in mechanical ventilator circuits. Am J Med 1984; 77: 834-838
    CrossrefGoogle Scholar
  • 23 Branson RD. The ventilator circuit and ventilator-associated pneumonia. Resp Care 2005; 50: 774-787
    Google Scholar
  • 24 Prävention der nosokomialen Pneumonie. Bundesgesundheitsbl Gesundheitsforsch Gesundheitssch 2000; 43: 302-309
    Google Scholar
  • 25 Han J, Liu Y. Effect of ventilator circuit changes on ventilator-associated pneumonia: a systematic review and meta-analysis. Resp Care 2010; 55: 467-474
    Google Scholar
  • 26 Lorente L, Lecuona M, Martin M et al. Ventilator-associated pneumonia using a closed versus an open tracheal suction system. Crit Care Med 2005; 33: 115-119
    CrossrefGoogle Scholar
  • 27 Altintas ND, Aydin K, Türkoglu MA et al. Effect of enteral versus parenteral nutrition on outcome of medical patients requiring mechanical ventilation. Nutrition in Clinical Practice 2011; 26: 322-329
    CrossrefGoogle Scholar
  • 28 O’Grady NP, Alexander M, Burns LA et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011; 52: 162-193
    CrossrefGoogle Scholar
  • 29 Morrow LE, Kollef MH, Casale TB. Probiotic prophylaxis of ventilator-associated pneumonia. Am J Respir Crit Care 2010; 182: 1058-1064
    CrossrefGoogle Scholar
  • 30 Gu WJ, Wei CY, Yin RX. Lack of efficacy of probiotics in preventing ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials. Chest 2012; DOI: 10.1378/chest.12-0679.
    Google Scholar
  • 31 Terragni PP, Antonelli M, Fumagalli R et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients. J Am Med Assoc 2010; 303: 1483-1489
    CrossrefGoogle Scholar
  • 32 Hess DR. Patient positioning and ventilator-associated pneumonia. Resp Care 2005; 50: 892-898
    Google Scholar
  • 33 Delaney A, Gray H, Laupland KB. Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care 2006; 10: R70
    CrossrefGoogle Scholar
  • 34 Labeau SO, Van de Vyver K, Brusselaers N et al. Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis 2011; 11: 845-854
    CrossrefGoogle Scholar
  • 35 Chan EY, Ruest A, O’Meade M et al. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: a systematic review and meta-analysis. Brit Med J 2007; 334: 889-1000
    CrossrefGoogle Scholar
  • 36 Lorente L, Lecunoa M, Jimenez A et al. Ventilator-associated pneumonia with or without toothbrushing: a randomized controlled trial. Eur J Clin Microbiol Infect Dis 2012; 31: 2621-2629
    CrossrefGoogle Scholar
  • 37 Schultz MJ, Haas LE. Antibiotics or probiotics as preventive measures against ventilator-associated pneumonia: a literature review. Crit Care 2011; 15: R18
    CrossrefGoogle Scholar
  • 38 de Smet AMGA, Kluytmans JAJW, Cooper BS et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009; 360: 20-31
    CrossrefGoogle Scholar
  • 39 de Smet AMGA, Bonten MJM, Kluytmans JAJW. For whom should we use selective decontamination of the digestive tract?. Curr Opin Infect Dis 2012; 25: 211-217
    CrossrefGoogle Scholar
  • 40 Oosdijk EAN, de Smet AMGA, Blok HEM et al. Ecological effects of selective decontamination on resistant gram-negative bacterial colonization. Am J Respir Crit Care Med 2010; 181: 452-457
    CrossrefGoogle Scholar
  • 41 Muscedere J, Rewa O, Mckechnie K et al. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis. Crit Care Med 2011; 38: 1985-1991
    Google Scholar
  • 42 Valencia M, Ferrer M, Farre R et al. Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trial. Crit Care Med 2007; 35: 1543-1549
    CrossrefGoogle Scholar
  • 43 Nseir S, Zerimech F, Fournier C et al. Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am J Respir Crit Care Med 2011; 184: 1041-1047
    CrossrefGoogle Scholar
  • 44 Kollef MH, Afessa B, Anzueto A et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia. J Am Med Assoc 2008; 300: 805-813
    CrossrefGoogle Scholar
  • 45 Lorente L, Blot S, Rello J. New issues and controversies in the prevention of ventilator-associated pneumonia. Am J Respir Crit Care Med 2010; 182: 870-876
    CrossrefGoogle Scholar
  • 46 Berra L, Coppadoro A, Bitter EA et al. A clinical assessment of the Mucus Shaver: a device to keep the endotracheal tube free from secretions. Crit Care Med 2012; 40: 119-124
    CrossrefGoogle Scholar
  • 47 Lorente L, Lecunoa M, Jimenez A et al. Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am J Crit Care Med 2007; 176: 1079-1083
    CrossrefGoogle Scholar
  • 48 Miller MA, Arndt JL, Konkle MA et al. A polyurethane cuffed endotracheal tube is associated with decreased rates of ventilator-associated pneumonia. J Crit Care 2011; 26: 280-286
    CrossrefGoogle Scholar
  • 49 Manzano F, Fernández-Mondéjar E, Colmenero M et al. Positive-end expiratory pressure reduces the incidence of ventilator-associated pneumonia in nonhypoxemic patients. Crit Care Med 2008; 36: 2225-2231
    CrossrefGoogle Scholar
  • 50 Schulze-Röbbecke R. Bündel zur Prävention nosokomialer Infektionen. Krankenh hyg up2date 2011; 6: 9-23
    Article in Thieme ConnectGoogle Scholar
  • 51 Al-Tawfiq JA, Abed MS. Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle. Am J Infect Control 2010; 38: 552-556
    CrossrefGoogle Scholar
  • 52 Morris AC, Hay AW, Swann DG et al. Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle. Crit Care Med 2011; 39: 2218-2224
    CrossrefGoogle Scholar
  • 53 Hawe CS, Ellis KS, Cairns CJS et al. Reduction of ventilator-associated pneumonia: active versus passive guideline implementation. Intensive Care Med 2009; 35: 1180-1186
    CrossrefGoogle Scholar