Risk factors for nosocomial pneumonia. Focus on prophylaxis.
Despite an increased understanding of the pathogenesis of NP and advances in diagnosis and treatment, the risk, cost, morbidity, and mortality of NP remain unacceptably high. This article has identified strategic areas for primary and secondary prophylaxis that are simple and cost-effective. Realizing that the pathogenesis of NP requires bacterial colonization and the subsequent entry of these bacteria into the lower respiratory tree helps highlight the role of cross-infection and the importance of standard infection control procedures. Similarly the role of sedation and devices as risk factors can be reduced by minimizing the duration and intensity of sedation and length of exposure to invasive devices. Additional low-cost interventions that have been shown to be effective in preventing NP are the positioning of patients in a semirecumbent position and the appropriate use of enteral feeding, antibiotics, and selected medical devices. Prophylaxis of NP and VAP is carried out best by a multidisciplinary management team comprised of physicians (critical care, pulmonary medicine, infectious diseases, and primary care), critical care and infection control nurses, and respiratory therapists, even though this approach may result in decreased professional autonomy and freedom. This group should review the current guidelines, pathways, and standards for short-term and long-term prophylaxis of NP and VAP, then integrate them into and monitor their use for routine patient care. The risk factors and prophylaxis strategies for NP discussed in this article apply primarily to patients in acute care facilities, but also are relevant to alternative health care settings as well as the care of ill patients in ambulatory settings. The routine use of effective team policies for prophylaxis needs to be monitored by the Joint Commission for the Accreditation of Health Care or other agencies. Research to delineate the most effective and feasible strategies for prophylaxis NP has been compromised by insufficient funding and lack of adequate, randomized multicenter studies to enable generalizability of results. Effective strategies for prophylaxis have not been disseminated widely or implemented in hospitals. Successful short-term and long-term strategies for prophylaxis must be evaluated and implemented by a team of physicians, nurses, and respiratory therapists. More than 100 years ago, Sir William Osler warned health care providers, "Remember how much you don't know." The authors would add that clinicians have acquired significant knowledge about risk factors and prophylaxis of NP in the 1980s and 1990s, but prophylaxis as a theory rather than an action. If the tree has not been planted, the time is now.
Fleming
C A
CA
Department of Medicine, Division of Infectious Diseases, Boston University School of Medicine, Boston, USA.
Balaguera
H U
HU
Craven
D E
DE
D003362:Cost-Benefit Analysis; D003422:Critical Care / Q000379:methods; D003428:Cross Infection / Q000191:economics / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy*; D006801:Humans; D017053:Infection Control / Q000191:economics / Q000379:methods*; D009017:Morbidity; D010348:Patient Care Team; D011014:Pneumonia / Q000191:economics / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy*; D011187:Posture; D011322:Primary Prevention / Q000191:economics / Q000379:methods*; D012121:Respiration, Artificial / Q000009:adverse effects; D012138:Respiratory Therapy / Q000379:methods; D012307:Risk Factors; D014481:United States / Q000453:epidemiology