Research Article: Preventable proportion of intubation-associated pneumonia: Role of adherence to a care bundle

Date Published: September 6, 2017

Publisher: Public Library of Science

Author(s): Antonella Agodi, Martina Barchitta, Annalisa Quattrocchi, Emiliano Spera, Giovanni Gallo, Francesco Auxilia, Silvio Brusaferro, Marcello Mario D’Errico, Maria Teresa Montagna, Cesira Pasquarella, Stefano Tardivo, Ida Mura, Yu Ru Kou.


The aim of the present study was to estimate the preventable proportion of Intubation-Associated Pneumonia (IAP) in the Intensive Care Units (ICUs) participating in the Italian Nosocomial Infections Surveillance in ICUs (SPIN-UTI) network, taking into account differences in intrinsic patients’ risk factors, and additionally considering the compliance with the European bundle for IAP prevention.

A prospective patient-based survey was conducted and all patients staying in ICU for more than 2 days were enrolled in the surveillance. Compliance with the bundle was assessed using a questionnaire for each intubated patient. A twofold analysis by the parametric g-formula was used to compute the number of infections to be expected if the infection incidence in all ICUs could be reduced to that one of the top-tenth-percentile-ranked ICUs and to that one of the ICU with the highest compliance to all five bundle components.

A total of 1,840 patients and of 17 ICUs were included in the first analysis showing a preventable proportion of 44% of IAP. In a second analysis on a subset of data, considering compliance with the European bundle, a preventable proportion of 40% of IAP was shown. A significant negative trend of IAP incidences was observed with increasing number of bundle components performed (p<0.001) and a strong negative correlation between these two factors was shown (r = -0.882; p = 0.048). The g-formula controlled for time-varying factors is a valuable approach for estimating the preventable proportion of IAP and the impact of interventions, based entirely on an observed population in a real-world setting. However, both the study design that cannot definitively prove a causative relationship between bundle compliance and IAP risk, and the small number of patients included in the care bundle compliance analysis, may represent limits of the study and further and larger studies should be conducted.

Partial Text

Healthcare-Associated Infections (HAIs), and especially those acquired in Intensive Care Units (ICUs), comprise the largest part of adverse events in the healthcare setting and affect patient morbidity and mortality. HAIs cause prolonged ICU and hospital length of stay, excessive utilization of antimicrobials and elevated costs [1, 2].

During the fourth edition of the SPIN-UTI project, a total of 3,009 patients were enrolled by 26 ICUs. For the present analysis, 1,169 patients (38.8% of the total) and 9 ICUs, were excluded (see S1 Text for details). Thus, a total of 1,840 patients (of which 1,494 with intubation) and of 17 ICUs were included in the analysis and their characteristics are detailed in Table 1.

ICU-acquired pneumonia has been associated with clinically important outcomes, including duration of mechanical ventilation or intubation, length of ICU-stay and increased mortality rates and healthcare costs [16–18]. The prevention of this severe infection has been the focus of numerous studies in critically ill patients and remains a controversial issue [19]. Different factors associated with infection rates can be targeted in order to control their incidence [12]. Particularly, the management of intubation procedures has been identified as a potential target for infection control interventions and, as such, there is the need for implementation of strategic bundles in order to decrease the growing risk of ICU-acquired pneumonia [8].




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