case study aspiration pneumonia

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16 Aspiration Pneumonia

• Published: February 2013
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Case 16 introduces a 77-year-old woman who is recovering from a recent cerebrovascular accident (CVA) that resulted in mild right-sided weakness and difficulty swallowing (dysphagia) presents with fever and increased respiratory rate. She had been well until 2 days earlier, when she began experiencing cough productive of greenish sputum. She notes that the cough has gotten progressively worse and kept her awake the previous night. She has had no blood in her sputum.

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Decisions on eating and drinking in older adults admitted with pneumonia and referred for swallowing difficulties

• Brief Report
• Open access
• Published: 09 May 2024

Cite this article

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• Yuki Yoshimatsu   ORCID: orcid.org/0000-0003-0913-3507 1 , 2 ,
• Dharinee Hansjee   ORCID: orcid.org/0000-0002-1137-9728 3 ,
• Marianne Markowski   ORCID: orcid.org/0000-0003-4652-3168 4 ,
• Ryan Essex   ORCID: orcid.org/0000-0003-3497-3137 4 &
• David G. Smithard   ORCID: orcid.org/0000-0001-6863-3099 1 , 2  

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Key summary points

We examined the frequency of different decisions, including eating and drinking with acknowledged risks (EDAR) in a single-institution retrospective study of older people with pneumonia and swallowing difficulties.

EDAR decisions were made in only a small fraction of patients (less than one fourth of patients on a modified diet). Most EDAR decisions were for end-of-life comfort care, and patients for EDAR had a significantly higher mortality despite the pneumonia recurrence rate not differing significantly.

The reasons underlying the relatively low frequency of EDAR decisions compared to modified diet needs to be investigated to maximise patient autonomy and comfort while minimising staff burden.

Older patients with pneumonia are commonly restricted from oral intake due to concerns towards aspiration. Eating and drinking with acknowledged risks (EDAR) is a shared decision-making process emphasising patient comfort. As part of our project to find the barriers and facilitators of EDAR, we aimed for this initial study to see how frequently EDAR was selected in practice.

We performed a retrospective cohort study at an acute hospital where EDAR was initially developed, of patients aged ≥ 75 years-old admitted with pneumonia and referred to speech and language therapy.

Out of 216 patients, EDAR decisions were made in 14.4%. The EDAR group had a higher 1-year mortality than the modified/normal diet groups ( p  < 0.001). Pneumonia recurrence rate did not differ significantly between the groups ( p  = 0.070).

EDAR decisions were comparatively less common and most were associated with end-of-life care. Underlying reasons for the low EDAR application rate must be investigated to maximise patient autonomy and comfort as intended by EDAR while minimising staff burden.

Avoid common mistakes on your manuscript.

Introduction

When a frail older adult is admitted to the hospital with pneumonia, the aetiology is frequently attributed to aspiration[ 1 , 2 ]. When aspiration is suggested, clinicians frequently restrict the patient from eating and drinking until assessed by a speech and language therapist (SLT). The SLT will advise on the patient’s ability to swallow safely. The management plan will vary from a normal diet (ND), through a modified diet (MD), or suggestion that the patient is too unsafe to eat and drink at all. Modified diet and nil-by-mouth (NBM) orders are associated with dehydration, malnutrition, oral health decline, poor quality of life and increased mortality[ 3 ].

For some patients, a better approach is to support them to eat and drink despite the risks; this is often termed “Risk Feeding” or “Eating and Drinking with Acknowledged Risks (EDAR).” EDAR is an alternative shared decision-making process that enables comfort, dignity, and autonomy for patients who prefer to continue oral intake, or where alternative management strategies such as tube feeding are inappropriate. In recent years, guidance has been developed by the Royal College of Speech and Language Therapists (RCSLT) to assist the decision-making process[ 4 ]. The recommended EDAR decision-making process includes a capacity assessment, a clinical evaluation of the swallow, establishing the goal of care, facilitating communication within the multidisciplinary team, and setting out an advance care plan where appropriate[ 4 ]. While the initial idea of EDAR may be suggested by the SLT, it is a patient-led decision. Capacity assessment forms part of the decision-making process, and the patient is always involved if they are capable. The Royal College of Physicians (RCP) has also published guidance on supporting people with eating and drinking difficulties[ 5 ].

However, questions have been raised regarding the risk management approach of the RCP guidance[ 6 ]. Moreover, despite guidance being available, in the clinical setting, supporting patients’ choices (or identifying patients who would benefit from EDAR even when their choice is unclear) and making these complex decisions remain a medical and ethical struggle. It is important to investigate how EDAR decisions are made in daily practice, to consider the next steps in further promoting it for appropriate patients.

We therefore conducted a retrospective study on how EDAR decisions are made in daily clinical practice in the management of older adults in hospital with a diagnosis of community-acquired pneumonia (CAP).

We performed a retrospective cohort study of older patients admitted with a diagnosis of pneumonia to Queen Elizabeth Hospital (Lewisham and Greenwich NHS Trust). Ethical approval was obtained from the Lewisham and Greenwich NHS Trust (Number 7211), and informed consent was waived due to the retrospective nature of the study.

We included patients aged 75 years-old and above admitted to the hospital with a diagnosis of CAP from 1st January 2021 to 31st December 2021 and were referred to an SLT for the assessment of suspected swallowing impairment. We excluded those who were admitted for COVID-19 pneumonitis, those who were admitted for more than once during the study period (only the first admission was included), those who did not have pneumonia according to the medical records, those who developed pneumonia after admission, and those admitted with a hospital acquired pneumonia.

We divided the patients into four groups according to the initial decisions made regarding their oral intake: the ND group, MD group, EDAR group, and NBM group. We compared the following between the four groups: patient backgrounds (age, Rockwood Clinical Frailty Scale (CFS)[ 7 ], initial diagnosis made by the consultant (aspiration pneumonia or non-aspiration pneumonia), pneumonia severity index (PSI)[ 8 ] and outcomes (in-hospital and 1-year mortality, pneumonia recurrence within 30 days). For the EDAR group, the reason for selecting EDAR was also extracted.

Statistical analyses

We used chi-square tests to compare outcomes and the one-way ANOVA test for continuous parametric variables (age, CFS and PSI). Analyses were performed using Microsoft Excel and online resources[ 9 ]. A p value < 0.05 was considered to be statistically significant for all analyses. Post hoc tests were performed where initial results indicated significant differences.

The initial list of 803 patients aged 75 years-old and above admitted with a diagnosis of CAP had a median age of 84 years-old (interquartile range 80–89) and a CFS score of 5 (4–6). 216 patients who underwent SLT assessment were included in the study (Fig.  1 ). Of these patients, 14.4% were considered appropriate for EDAR, 59.3% for MD, 19.9% for ND, and 6.5% for NBM. Demographic data and outcomes are summarised in Table  1 . Of the 31 patients who were eating and drinking with acknowledged risks, the reasons underlying the decisions were short life expectancy (58.1%), quality of life (38.7%), and refusing nasogastric tube feeding (3.2%). Only 19.4% of these patients were assessed as having the mental capacity to make these decisions. For those without capacity, attempts were made by the team to establish the wishes of the patient from significant others which forms part of the decision-making process. The EDAR decisions were mostly initiated by the SLT following a swallow assessment and then discussed with the doctor, patient (when having capacity), and family member. A shared decision making process was co-ordinated by SLT to ensure the patient’s views are included as part of the MDT decision.

Patient selection.  CAP community-acquired pneumonia, HAP hospital-acquired pneumonia, SLT speech and language therapist

Patient background

The patients included in the study had a median age of 86 years-old (interquartile range: 81–91). As shown in Table  1 , significant differences among groups were indicated for frailty and being diagnosed with aspiration pneumonia. Post-hoc Tukey’s test revealed a statistically significant difference in CFS between the EDAR and ND groups (F(3212) = 4.14, p  = 0.010) but not among any other groups. Post hoc comparison with Bonferroni correlation (adjusted alpha = 0.00625) indicated that an aspiration pneumonia diagnosis was significantly more common in the EDAR group than the ND group ( p  < 0.001) but not among any other groups.

The EDAR and NBM groups showed a high short/long-term mortality, with half dying during the hospital stay and over 90% dying within a year. Bonferroni correlation (adjusted alpha = 0.00625) indicated that in-hospital mortality was significantly higher in the NBM group than in each of the three other groups ( p  < 0.001), but there were no significant differences among other groups. One-year mortality was significantly higher in the EDAR group compared to the ND group ( p  = 0.001) and MD group ( p  = 0.001), and in the NBM group compared to the ND group ( p  < 0.001) but not with any other groups. The pneumonia recurrence rate within 30 days did not differ significantly among the groups ( p  = 0.070), as shown in Table  1 .

Our study revealed how EDAR decisions were not common in older patients diagnosed with pneumonia; EDAR decisions were made for one-fourth of patients compared to those offered MD alone. Reasons for this may include patient choice, physical condition, staff anxiety towards potentially contributing to risks of pneumonia and patient discomfort, staff members’ lack of awareness/understanding on EDAR, or staff members understanding but not wanting to support EDAR. Despite the setting being where EDAR was originally developed[ 10 ], there may still be a degree of insufficient awareness and understanding of EDAR. This was implied by the data that EDAR was chosen in more frail patients with higher severity of pneumonia, with the majority being chosen for end-of-life comfort care rather than a way to continue oral intake in patients with treatable pneumonia. This indicates a necessity for continuous education and training in the workplace. Choices and preferences, which form the foundation of EDAR decisions are not merely a part of terminal care but is also integral in the acute stages of disease. EDAR was established to enable patients the choice to continue oral intake regardless of disease stage, particularly where the patient refuses to accept modified food and liquids. It may be important at this stage to reconsider how and to whom to offer EDAR as a viable option.

The prognosis of older adults diagnosed with pneumonia (aspiration pneumonia in particular) is considerably poor[ 11 , 12 ], and multimodal multidisciplinary care is imperative[ 13 ]. It is important to have discussions regarding patients’ preference in eating and drinking and make a shared decision[ 14 ], rather than making assumptions about patient perception and paternalistically making a ‘safe’ decision[ 15 ]. Issues have been raised regarding the RCP guidance on EDAR, with concerns towards the risk management approach being standardised than an evidence-based informed consent approach[ 6 ]. With EDAR guidance being published, it is our responsibility as clinicians to ensure patients’ rights are protected, while also devoting attention towards the potential barriers such as staff anxiety and knowledge[ 16 ]. Adverse events such as pneumonia or choking may be another concern when considering EDAR. While our data shows that pneumonia recurrence within 30 days was not a significant concern, previous reports have shown increased readmissions with EDAR-linked conditions such as chest infections and reduced oral intake[ 17 ]. It is important to assess which patients are appropriate for EDAR, and monitor them throughout the course through to discharge where appropriate documentation of decisions is carried through into the community.

Eating and drinking is a basic right, and decisions for or against it are not straightforward. Clinicians have the responsibility to act under the basic ethical principles of medical ethics—autonomy, beneficence, non-maleficence and justice[ 18 ]. All individuals have the freedom to eat and drink as they wish ( autonomy ). However, as it could cause harm and discomfort to the patient, clinicians provide recommendations based on the evaluated risks ( non-maleficence ), and may recommend alternative methods of nutritional intake if deemed appropriate ( beneficence). These recommendations, however, do not always align with patient autonomy and bring forth dilemmas in the decision-making process. In addition, interventions related to dysphagia, including EDAR, are often inaccessible, leading to difficulties in maintaining equity across the community and globally ( justice ). These aspects support the importance of having guidance regarding decision-making in eating and drinking and increasing its awareness to provide a basis for all clinicians regardless of profession or setting, while additional case-based training is essential in the implementation and adaptation of EDAR and other methods in practice, as evidenced by clinical data. While EDAR is beneficial for some individuals, it is not always the best choice for individuals and caregivers, and the key lies in how to evaluate appropriate situations as a multidisciplinary team. The ethical balance between providing comfort and considering safety, or emphasising patient autonomy while being a responsible healthcare professional, is not a simple dilemma. Multidisciplinary team discussions with added expertise from stakeholders of other related specialties such as palliative care may be beneficial.

Strengths and limitations

Some limitations must be mentioned. This study was a single-centre, retrospective study where EDAR was originally developed, and results may not translate to situations in other regions or institutions. There is a well-established dissemination route on EDAR policy and practice through robust training programmes delivered to nurses and medical staff in the developing hospital. The likelihood therefore of EDAR being initiated and utilised appropriately at the developing hospital over other institutions is higher. However, this was a relatively large study in a 521-bed hospital. There have been no similar studies of EDAR in this population. This highlights the value of this study for the next steps. This will provide a basis for addressing the complex decision-making process surrounding EDAR and what can be done to make it easier for clinicians and patients.

EDAR decisions were made mostly as part of end-of-life care. EDAR should also be offered to appropriate patients in earlier disease stages, as comfort, dignity and autonomy are a priority regardless of disease stage. Underlying reasons for the low EDAR application rate must be investigated to maximise patient autonomy and comfort while minimising staff burden.

Data availability

All data are applicable in the paper.

Yoshimatsu Y, Smithard DG (2022) A paradigm shift in the diagnosis of aspiration pneumonia in older adults. J Clin Med. 11(17):5214

Article   PubMed   PubMed Central   Google Scholar  

Smithard DG, Yoshimatsu Y (2022) Pneumonia, aspiration pneumonia, or frailty-associated pneumonia? Geriatrics (Basel). 7(5):115

Maeda K, Koga T, Akagi J (2016) Tentative nil per os leads to poor outcomes in older adults with aspiration pneumonia. Clin Nutr 35(5):1147–1152

Article   PubMed   Google Scholar  

D. Hansjee, N. Burch, L. Campbell, H. Crawford, Crowder R, D. Garrett, et al 2021 Eating and drinking With acknowledged risks: multidisciplinary team guidance for the shared decision-making process (adults) [Working Paper] London UK

Porter K, Burch N, Campbell C, Danbury C, Foster C, Gabe S, Goddard A, Harp K, Holdoway A, Hughes T, Le Ball K (2021) Supporting people who have eating and drinking difficulties. Clinical med 21(4):e344

Article   Google Scholar  

O’Keeffe ST, Murray A, Leslie P, Collins L, Lazenby-Paterson T, McCurtin A et al (2021) Aspiration, risk and risk feeding: a critique of the royal college of physicians guidance on care of people with eating and drinking difficulties. Adv Commun Swallowing. https://doi.org/10.3233/ACS-210031

Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I et al (2005) A global clinical measure of fitness and frailty in elderly people. CMAJ 173(5):489–495

Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE et al (1997) A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 336(4):243–250

Article   CAS   PubMed   Google Scholar  

Social Science Statistics. https://www.socscistatistics.com/ .

Hansjee D (2018) An acute model of care to guide eating & drinking decisions in the frail elderly with dementia and dysphagia. Geriatrics (Basel). 3(4):65

Yoshimatsu Y, Thomas H, Thompson T, Smithard DG (2024) Prognostic factors of poor outcomes in pneumonia in older adults: aspiration or frailty? European Geriatric Medicine. 15(2):481–488

Yoshimatsu Y, Kragholm K, Clemmensen SZ, Melgaard D, Torp-Pedersen C, Smithard DG et al (2024) The predictive value of anticholinergic drug exposure and the outcome of pneumonia: a danish database study. Age Ageing. https://doi.org/10.1093/ageing/afae012

Yoshimatsu Y, Ohtake Y, Ukai M, Miyagami T, Morikawa T, Shimamura Y et al (2023) Diagnose, Treat, and SUPPORT clinical competencies in the management of older adults with aspiration pneumonia: a scoping review. Eur Geriatr Med 15(1):57–66

O’Keeffe ST, Leslie P, Lazenby-Paterson T, McCurtin A, Collins L, Murray A et al (2023) Informed or misinformed consent and use of modified texture diets in dysphagia. BMC Med Ethics 24(1):7

Leslie P, Lisiecka D (2020) Ethical issues in dysphagia management. Semin Speech Lang 41(3):257–265

Murray A, Mulkerrin S, O’Keeffe ST (2019) The perils of “risk feeding.” Age Ageing 48(4):478–481

Sommerville P, Hayton J, Soar N, Archer S, Fitzgerald A, Lang A et al (2022) Prognosis in dysphagic patients who are eating and drinking with acknowledged risk: results from the evaluation of the FORWARD project. Age Ageing. https://doi.org/10.1093/ageing/afac005

Beauchamp T, Childress J (2012) Principles of biomedical ethics, 7th edn. Oxford University Press, Inc, Oxford

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Funding received from Japanese Respiratory Society, 2021, Yuki Yoshimatsu, The Great Britain Sasakawa Foundation, B149, Yuki Yoshimatsu.

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The corresponding author is supported by The Japanese Respiratory Society Fellowship Grant. This study was funded by the Great Britain Sasakawa Foundation (Butterfield Award). The sponsors had no role in this study design, review process, writing of the manuscript, or decision to publish. The authors received no other financial support for the research, authorship and publication of this article. The authors declare that they have no other competing interests.

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Yoshimatsu, Y., Hansjee, D., Markowski, M. et al. Decisions on eating and drinking in older adults admitted with pneumonia and referred for swallowing difficulties. Eur Geriatr Med (2024). https://doi.org/10.1007/s41999-024-00983-2

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The spectrum of pneumonia among intubated neonates in the neonatal intensive care unit

• Dayle J. Bondarev   ORCID: orcid.org/0000-0003-2443-2732 1 ,
• Rita M. Ryan   ORCID: orcid.org/0000-0002-4588-3412 1 &
• Devashis Mukherjee   ORCID: orcid.org/0000-0002-6812-8970 1  

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• Bacterial infection
• Respiratory tract diseases

We review the pathophysiology, epidemiology, diagnosis, treatment, and prevention of ventilator-associated pneumonia (VAP) in neonates. VAP has been studied primarily in adult ICU patients, although there has been more focus on pediatric and neonatal VAP (neo-VAP) in the last decade. The definition as well as diagnosis of VAP in neonates remains a challenge to date. The neonatal intensivist needs to be familiar with the current diagnostic tools and prevention strategies available to treat and reduce VAP to reduce neonatal morbidity and the emergence of antibiotic resistance. This review also highlights preventive strategies and old and emerging treatments available.

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Introduction.

Invasive mechanical ventilation (IMV) through an endotracheal tube (ETT) continues to progress and evolve in neonatology. It is still a challenge to avoid ventilator-induced lung injuries (VILI) such as volutrauma, barotrauma, and atelectotrauma, inducing lung remodeling and repair. Despite advances in non-invasive ventilation (NIV), IMV is unavoidable for some neonates. Prolonged IMV can lead to VILI, pulmonary interstitial emphysema (PIE), air leaks, subglottic stenosis, as well as ventilator-associated pneumonia (VAP) [ 1 ].

The definition of VAP in the neonatal world remains unclear. The Centers for Disease Control and Prevention (CDC) have defined VAP as pneumonia associated with the use of IMV for at least two consecutive days [ 2 ]. The CDC and the National Nosocomial Infections Surveillance (NNIS) criteria both define VAP in infants less than one year old who require invasive mechanical ventilation (IMV) for 48 h, but they do not have definite criteria for newborns or premature neonates. The CDC’s definition for VAP states that IMV for at least 2 consecutive days is required for this diagnosis, along with demonstration of worsening gas exchange and evidence of the radiographic finding of new or worsening pulmonary infiltrate [ 2 ]. The current CDC criteria for VAP defined for an infant ≤1 year old must include worsening gas exchange and at least 3 of the following: temperature instability, leukopenia or leukocytosis, cough, new onset purulent sputum, change in character in sputum or increase in respiratory secretions, apnea, increased work of breathing, wheezing, rales or rhonchi and bradycardia or tachycardia (Table  1 ). VAP is a clinical entity that neonatologists must manage and still needs a proper national definition.

The incidence of VAP in the neonatal ICU is dependent on the gestational age (GA) of the population, the presence of high-risk patients (such as patients with bronchopulmonary dysplasia, sedation requirements or a history of multiple intubations) as well as geographic location [ 3 , 4 ]. In addition, reporting the incidence can be a challenge as the definition of neo-VAP can vary within different institutions. In developed countries, the reported incidence of VAP is between 5.8 and 19.7 episodes per 1000 ventilator days, compared with 37.2 per 1000 ventilator days in developing countries [ 5 ]. The variability in this incidence may be attributed to the lack of a clear definition of neonatal VAP (neo-VAP). In addition, although neonatologists at various institutions often use the CDC criteria for infants <1 year of age for the diagnosis of neonatal VAP, some institutions use their own criteria. This may contribute to the difference in incidence among centers.

This review aims to present the scientific literature on neo-VAP, including its pathogenesis, diagnosis, outcomes, preventive strategies, and old and emerging treatments available.

Pathogenesis

Pathogenesis of VAP in neonates is multi-factorial. Figure  1 shows the key innate and adaptive immune mechanisms that prevent upper and lower respiratory tract infections. Neonates are predisposed to nosocomial infections due to their immature immune system [ 6 ]. In addition, the skin and mucous membranes of premature neonates are not as effective in preventing infection as full-term neonates due to their increased permeability [ 7 ]. Premature neonates have an inadequate reserve of preformed neutrophils to mount an immune response, have immature granulocyte migration and bacterial phagocytosis, and have decreased immunoglobulins, as most transfer of immunoglobulins occurs during the third trimester of pregnancy [ 8 , 9 ]. Lastly, there is evidence to show that the airway epithelium in preterm neonates is both functionally and structurally altered after preterm birth. There is goblet cell hyperplasia, leading to mucus hypersecretion and further airway obstruction, thickening of the ciliated portion of the epithelium, and increased number of apoptotic cells. Airway obstruction secondary to hypersecretion can decrease airway clearance and increase predisposition to VAP [ 10 ].

ROS reactive oxygen species, RNS reactive nitrogen species, AECs alveolar epithelial cells, BECs bronchial epithelial cells, ILCs innate lymphoid cells, DCs dendritic cells, HEV high endothelial venule, BALT bronchus-associated lymphoid tissue, iBALT BAL induced in response to infection. Adapted from Kumar V, Front. Immunol 2020 and Adivitiya et al. Biology (Basel) 2021 [ 86 , 87 ]. Certain parts of this image have been created with BioRender.com.

Endotracheal intubation impairs the natural defense system of mucus clearance. It connects the lungs with the oropharynx, eliminating the glottis’s natural barrier and allowing easy transfer of oral pathogens into the lower respiratory tract [ 11 ]. Duration of IMV is an independent risk factor associated with increased risk of VAP in neonates [ 12 ]. The oropharynx and pulmonary airways are colonized by non-pathogenic bacteria, which rarely cause disease. Antibiotic use and critical illness result in an abnormal host environment, leading to loss of normal flora and overgrowth of pathogenic species [ 13 , 14 ]. These factors combine to predispose premature intubated neonates to acquire lower respiratory tract infections (Table  2 ).

Staphylococcus and Ureaplasma are some of the earliest colonizers of the upper airway tracts, appearing within the first five days of life in preterm mechanically ventilated infants [ 15 ]. Other bacterial pathogens which colonize neonatal ETTs include Klebsiella , Streptococcus , and Pseudomonas [ 15 ]. A cohort of 71 neonates had tracheal aspirates obtained within seven days of age and grouped into different clusters of either pro-inflammatory state or anti-inflammatory state. The study revealed that while Staphylococcus was the predominant species, Ureaplasma was not detected in the anti-inflammatory samples, suggesting that Ureaplasma may play a role in airway inflammation [ 16 ]. Collectively, these findings suggest that Staphylococcus is a common colonizer that serves as a commensal organism, and there are potential organisms that elicit a pro-inflammatory state. The microbiology of the ETT tip in neonates correlates closely with the subglottic area rather than the oropharyngeal area [ 17 ]. In summary, no particular organism is predominant in neo-VAP; hence, antimicrobial therapy reflects coverage for most gram-positive and gram-negative organisms.

As the upper respiratory airway tracts are constantly exposed to pathogens (either naturally or from nosocomial sources such as suctioning, infant handling, etc.), innate and adaptive immune defenses work in synchrony to clear the respiratory tract of microbes to enable adequate air exchange (Fig.  1 ). In preterm neonates, lung injury from prolonged ventilation and physical blockage of the endotracheal tube can inhibit pathogen clearance in the lower airway tract, allowing the proliferation of microbes, inflammation, and infection.

Another possible etiology for VAP is that reflux from the gastric fluid can cause gastric bacteria to transit into the airways [ 18 ]. This theory remains controversial as studies in the adult and pediatric populations have not consistently proven that acid-suppression prophylaxis prevents VAP [ 19 , 20 , 21 , 22 ]. The concept that microorganisms from the gastrointestinal tract can be present in the trachea is corroborated by data presented previously from El Abiad et al. in a single-center study in which there was 71% concordance between the organisms isolated from tracheal and gastric aspirates [ 22 , 23 ].

Biofilms are structured communities of bacteria enclosed in a polymeric matrix adherent to an inert or living surface [ 13 ]. Any medical device or implant is a source of biofilm formation and thus can be a permanent source of infection. Intubation bypasses the upper airway, which decreases upper airway bacterial clearance and allows direct passage to the lower respiratory tract, which helps the ETT to act as a reservoir for biofilm formation [ 24 , 25 ]. Suctioning the ETT can detach the biofilm from the ETT, which can then migrate towards the lower respiratory tract by the ventilator’s positive pressure. Feldman et al. showed that the secretions and airway access tubing lining the interior distal third of the ETT formed a biofilm [ 26 ]. The microflora in the ETT biofilms have shown an abundance of Streptococci in the neonatal ETT biofilms and is significantly related to the onset of VAP and colonization by other nosocomial pathogens such as Pseudomonas aeruginosa [ 27 ].

There is no consensus statement from the American Academy of Pediatrics Section on Neonatal Perinatal Medicine or the Committee on Infectious Diseases on the definition of VAP in neonates. The CDC’s definition of VAP includes both clinical and radiographic findings. It is important to note that the rapid resolution of radiographic findings suggests a non-infectious process, such as atelectasis or congestive heart failure, and is inconsistent with VAP [ 28 ]. Frequent chest X-rays can be helpful since a longer course of antibiotics could be avoided when rapid resolution of lung “infiltrates” occurs. Chest radiograph findings can range from focal consolidates to subtle areas of infiltrates (Fig.  2 ).

This radiograph was used to diagnose a ventilator-dependent 5-week-old, 27-week GA male with Klebsiella pneumoniae and Staphylococcus aureus pneumonia. CDC Centers for Disease Control and Prevention, GA gestational age.

Prematurity, longer hospital length of stay, and low birth weight are among the risk factors for VAP identified in the preterm population [ 12 ]. Sedation has also been associated with an increased risk of VAP, perhaps due to less ability to take deep sighs or to clear the airways [ 3 ]. Although multiple reintubation attempts have been associated with increased VAP incidence, this is likely due to a positive association between a higher number of reintubation attempts, increased IMV days, and lower birth weight, both of which are independently associated with increased VAP incidence [ 29 ].

Per CDC guidelines, at least one of the following must be collected to identify the causative organism for VAP: blood culture, pleural fluid, quantitative culture from minimally contaminated lower respiratory tract specimen such as broncho-alveolar lavage (BAL), protected specimen brushing or endotracheal aspirate [ 2 ]. In adults, BAL and bronchoscopic brushings are commonly used to collect airway samples to avoid contamination from the upper respiratory tract [ 30 ]. However, these techniques must be performed with bronchoscopic video guidance, which can be challenging to perform via the smaller endotracheal tubes and airways of neonates, and, often, appropriately sized equipment is a limiting factor. While tracheal aspirates (TAs) are more easily obtained from neonates, results can yield non-infectious colonizers, leading to unnecessary antibiotic usage, the development of antibiotic resistance, and the emergence of multi-drug resistant (MDR) organisms [ 31 ]. Also, evidence shows that TAs growing bacteria do not always represent clinical infection. In a retrospective cohort study in a level IV neonatal intensive care unit (NICU) where TA cultures were obtained in intubated neonates, positive cultures were not significantly associated with clinical, laboratory, or radiographic markers used to screen for infection [ 32 ]. Non-bronchoscopic BAL or “deep pulmonary lavage,” which employs blind wedging of the catheter below the carina, is also an option for obtaining samples that is a relatively safe diagnostic tool [ 33 , 34 , 35 ]. Although the utility of this technique in neonates is unclear, it has been used in randomized trials [ 36 , 37 ]. Regardless of the sampling method, distinguishing VAP from colonization can be challenging. A cohort of preterm infants with bronchopulmonary dysplasia (BPD) requiring IMV for 21 days with serial TAs obtained at 72 h, seven days, 14 days, and 21 days of age showed that early bacterial colonization with diverse species is present within the first three days of life [ 38 ].

The CDC defines purulent sputum as secretions that contain ≥25 neutrophils and ≤10 squamous epithelial cells per low-power field. If the laboratory cannot provide additional information on quantitative reporting, they suggest direct examination results of “many,” “heavy,” “numerous 4+,” or ≥25 neutrophils per low power field to be interpreted as purulent secretions [ 26 ]. Alriyami et al. recommend the collection of TAs before and 24 to 48 h after empiric antibiotic treatment to assess changing microbiological patterns, including a decrease in colony counts or whether a polymicrobial sample shifts to a dominant organism, which is suggestive of resistance [ 22 ].

Obtaining a blood culture in the setting of pneumonia is controversial. The multicenter Etiology of Pneumonia in Community (EPIC) study showed that bacteremia was uncommonly detected in pediatric patients with community-acquired pneumonia and concluded that blood culture was low yield but could have utility in patients with parapneumonic effusion and intensive care unit (ICU) admission [ 39 ]. No study to date assesses the utility of blood culture in the setting of presumed VAP in preterm neonates. However, due to increased predisposition to infection in preterm neonates and the fact that the presentation of sepsis is similar to VAP in neonates, most neonatologists obtain blood cultures when there is a concern for VAP. Obtaining a blood culture will also allow a shorter antibiotic course if the culture does not detect bacteremia.

In a prospective study of extremely preterm neonates who were diagnosed with VAP using CDC guidelines, the most common pathogenic micro-organisms identified from respiratory secretions were Pseudomonas aeruginosa, Enterobacter spp ., and Klebsiella for Gram-negative bacteria, and Staphylococcus aureus and Enterococcus spp . for Gram-positive bacteria [ 40 ]. In another study of neonates with a definite diagnosis of VAP (defined using the CDC criteria), 25% were polymicrobial VAP. Clinical features, therapeutic responses, and outcomes did not differ between monomicrobial and polymicrobial VAP in this cohort. Therapeutic response was defined by lack of treatment failure. Treatment failure of VAP included neonates who died from VAP, required antibiotics for more than two weeks, progression to bacteremia, and clinical deterioration after seven days of effective antibiotic treatment [ 41 ].

Endotracheal fungal colonization can also be found in 8.3–42% of intubated premature neonates [ 42 ]. Anti-fungal coverage should be considered for neonates not responding to antibacterial drugs or if the neonate has hyperglycemia, thrombocytopenia, and signs of skin involvement [ 43 ].

Specific biomarkers for pneumonia have been extensively studied in adults and may be helpful in neonates. C-reactive protein (CRP) is a well-studied marker in neonates and is used as a biomarker in sepsis [ 44 ]. CRP is a pentraxin protein produced by hepatocytes as an indirect response to inflammation. As tissue damage occurs, cytokine release triggers the hepatocytes to produce CRP that peaks within 4-6 h upon the onset of inflammation [ 44 ]. Single-center studies have shown that serum CRP is elevated in the majority of neonates diagnosed with VAP [ 45 , 46 ]. The BioVAP study is a prospective multicenter observational study that evaluated the utility of CRP and procalcitonin in adults who received mechanical ventilation for >72 h. Their results showed that CRP and its rate of change per day (CRP ratio) were the best predictors of VAP in their patient cohort [ 47 ]. In a prospective cross-sectional study among 320 neonates with a cut-off value of 3.6 ng/mL, pooled sensitivity was 78%. At the same time, specificity was 70% in diagnosing neonatal sepsis [ 48 ]. Brown et al. performed a meta-analysis of 2 225 infants with sepsis and reported a median specificity of CRP of 74% with a median sensitivity of 62%, concluding that CRP may not be a valuable tool to withhold antibiotics considering an ongoing infection [ 49 ]. Both studies reflect that CRP can potentially be used in the correct clinical context of sepsis. Hence, the absence of CRP elevation does not rule out sepsis if the clinical picture suggests otherwise. Perhaps the trend of CRP can be used to guide treatment efficacy. In addition, it is essential to note that these studies are focused on neonatal sepsis as opposed to VAP. No studies have investigated the sensitivity and specificity of CRP in neo-VAP.

Another biomarker that could be utilized to diagnose VAP is procalcitonin (PCT). PCT was initially found to be increased in patients with staphylococcal toxic shock syndrome, and this resulted in numerous studies to assess the utility of PCT as a biomarker for sepsis [ 50 ]. PCT is a prohormone secreted as part of the inflammatory response to endotoxins in response to bacterial infection. In bacterial infection, inflammatory cytokines (such as tumor necrosis factor-alpha, IL-1β, and IL-6) induce gene expression responsible for PCT production. Cytokines that are selectively increased in response to viral infection do not cause the same upregulation of PCT compared to specific bacterial cytokine markers [ 51 ]. PCT can be used reliably to rule out bacterial infection [ 52 ]. In a multicenter randomized controlled trial (NeoPIns), 1 408 neonates were randomized either to PCT-guided decision-based versus standard care-based antibiotic treatment for early-onset sepsis, and the results showed that neonates enrolled under PCT-guided decision-making had a shorter duration of antibiotic use compared to the control group, without increase in any adverse events. Some neonatal and pediatric VAP studies have shown that PCT has an 80–90% sensitivity [ 53 , 54 ]. A meta-analysis of 39 studies comparing PCT and CRP revealed that the mean sensitivity of early-onset sepsis (EOS), late-onset sepsis (LOS), and both EOS and LOS combined are 73.6%, 88.9%, and 76.5% respectively suggesting that procalcitonin is superior to CRP. However, only four studies included VLBW in their analysis [ 55 ]. This poses the same dilemma as CRP as these studies reflect neonatal sepsis, as opposed to neo-VAP. However, PCT may have a role in monitoring ongoing infections.

Presepsin is another potential biomarker/indicator of early-onset sepsis and has been evaluated in the diagnosis of VAP in the adult and pediatric populations. Presepsin is a product of the cleavage of CD14 from bacterial proteases during sepsis [ 56 ]. A recent meta-analysis of presepsin utility in diagnosing early-onset neonatal sepsis showed high sensitivity (93%) and specificity (91%), and its accuracy was not affected by the GA of the patients [ 57 ]. A cross-sectional observational study performed in intubated neonates from whom TAs were analyzed for presepsin showed that TA presepsin suggested the presence of early-onset pneumonia based on CDC criteria [ 58 ]. These studies show some promising utility of presepsin and its association with neo-VAP.

Point-of-care ultrasound is increasingly used for the diagnosis of VAP as an interpretation of radiographs can be challenging in patients with underlying chronic lung disease. When lung ultrasound was studied as a potential diagnostic tool for VAP, it showed a sensitivity of 94% with an area under the curve of 0.97. In this study, neo-VAP was determined by a multi-parameter ventilator-associated pneumonia score adapted from Goerens et al. and respiratory deterioration and confirmed by isolation of pathogenic microorganisms in airway aspirate. The criteria for lung ultrasound findings concerning for neo-VAP include the presence of consolidation ( >0.5 cm), pleural effusion, arborescence, or linear dynamic bronchograms [ 59 ].

VAP has been associated with increased healthcare costs. A study by Ratcheva et al. demonstrated that in a cohort of 107 neonates on MV for >48 h, the length of stay for patients who met the criteria for VAP was 32 days compared to 18 days for non-VAP patients. The median hospital cost for patients with VAP is €3675.77, compared to the lower expenses of €2327.78 for non-VAP patients (U = 1791.5, p  < 0.001) [ 60 ]. In addition to increased healthcare costs, VAP is also associated with higher morbidity and mortality. In a prospective cohort study in the US of 229 patients admitted to the NICU with a birth weight ≤ 2000 grams receiving at least 48 h of IMV, 28.3% met the CDC VAP criteria for infants. The authors demonstrated a significant association between VAP and mortality in neonates who stayed in the NICU for greater than 30 days (RR 8 with 95% CI 1.9–35) [ 40 ]. This highlights the importance of monitoring VAP to decrease mortality. A prospective cohort study of 199 inborn neonates who were mechanically ventilated for 48 h was classified as either exposed or unexposed to VAP defined by CDC < 1-year-old criteria. The study revealed that the incidence of BPD was higher in VAP patients with an adjusted relative risk ratio of 3.5 (1.002–12.7, P  = 0.049) and the number needed to harm of 2.07. However, the composite outcome of BPD/mortality did not differ. Infants diagnosed with VAP are also smaller in GA and have longer IMV duration, both of which are risk factors for BPD. This emphasizes the importance of hypervigilance with the diagnosis and treatment of neo-VAP in the ELBW population with pre-disposition to BPD. In addition, VAP-exposed neonates had a longer length of stay (87 [43–116] vs 14 [8–52] days, P  < 0.0001) as well as fewer ventilator-free days (22 [14–24] vs 11 [5–17.7] days, P  = 0.05) compared to non-exposed neonates, which remained statistically significant after adjusting for GA. Respiratory infections, rehospitalization, and home oxygen therapy were similar in VAP and non-VAP cohorts [ 61 ]. In another prospective study by Wang et al., neonates with polymicrobial VAP were shown to have a significantly increased incidence of neurological sequelae with an adjusted odds ratio of 2.74 (95% CI 1.18–6.36, P  = 0.019) [ 41 ].

The emergence of MDR organisms can be a sequela of utilizing broad-spectrum antibiotics to treat VAP in the NICU. Wang et al. reported the incidence of MDR neo-VAP was 39.2%, and these neonates were shown to have a longer duration of antibiotic use and delayed resolution of symptoms [ 62 ]. This highlights the importance of identifying microbes involved in VAP to narrow antibiotic coverage to prevent the emergence of MDR organisms. This is one example in which TA cultures can be helpful.

Understanding the microbiology of VAP is essential to making an informed decision on empiric antibiotic treatment, followed by narrowing it down to specific targeted therapy based on microbial sensitivities or discontinuing antibiotics.

Most management data in neo-VAP is focused on neonatal sepsis rather than VAP. In addition, there are no uniform recommendations regarding antibiotic guidance for neo-VAP, and most centers use empiric antibiotic therapy in VAP as they would for early or late-onset neonatal sepsis. Current recommendations are to use ampicillin and gentamicin for early-onset sepsis (within 72 h of birth) and nafcillin and gentamicin for late-onset sepsis [ 63 ]. Broad coverage for the source of infection targeting known typical nosocomial flora, antibiotic susceptibilities of previous infections, and antibiogram patterns for each NICU should all be considered. Empiric antibiotics for late-onset infection should cover Staphylococcus species and Gram-negative bacteria such as Pseudomonas aeruginosa, Klebsiella spp, Escherichia coli , and Serratia marcescens . If there is an associated risk of aspiration, anaerobic coverage should also be considered. In infants who do not seem to be improving, a third or fourth-generation cephalosporin (e.g., ceftazidime or cefepime) with pseudomonal coverage is recommended, as well as adding vancomycin for methicillin-resistant staphylococcal coverage. When these higher-level antibiotics are being used, it is prudent to involve pediatric infectious disease specialists with expertise in antimicrobial stewardship to limit antibiotic resistance in the NICU.

Inhaled antibiotics reduce systemic toxicity as they are given locally with limited systemic absorption. Nakwan et al. reported treatment of Acinetobacter baumanii in a small cohort of preterm neonates using aerosolized colistin for 72 h as an adjunct to standard intravenous antibiotic treatment [ 64 ]. This was a retrospective matched case-control study in 16 neonates with MDR Gram-negative VAP and showed that neonates who received both intravenous and inhaled colistin had a higher clinical cure and microbial eradication, along with lower ventilator requirements at the end of treatment as compared with neonates receiving intravenous colistin alone [ 65 ]. These studies show some clinical evidence for adding an inhaled antibiotic, but a more extensive cohort study is needed to confirm clinical efficacy. However, it is crucial to recognize that inhaled or oral drugs are not typical treatments for neonatal pneumonia in the setting of presumed sepsis. Although it is used in some NICUs, there has not been a large cohort study on inhaled antibiotics in preterm neonates to assess their efficacy and toxicity.

There is no consensus on the duration of treatment of neo-VAP. However, Goerens et al. provided a recommendation for suspected VAP and length of treatment based on clinical status and laboratory findings of (1) worsening clinical and ventilation conditions, (2) abnormal laboratory findings (CRP > 20 mg/l), leukopenia (≤4000 WBC/mm3) or leukocytosis (>15,000 WBC/mm3) and left shift (>10% band forms), (3) and positive cultures from tracheal secretions. If all three criteria are met, the authors recommend a duration greater than or equal to 7–14 days of antibiotic therapy. A treatment of 24–36 h plus an additional 48–72 h would be warranted if the patient only shows 1–2 of the criteria, and discontinuation of antibiotics after 24–36 h if only 0–1 of the criterion is met [ 5 ]. Figure  3 shows a modified adaptation from Goerens et al. which can serve as a clinical decision-making tool for the neonatologist at the bedside. It is important to note that this is a proposed algorithm, and data has not been published to assess its efficacy. The clinical rounding team should frequently discuss the duration and choice of antibiotic therapy with the clinical pharmacist. In addition, consulting the pediatric infectious disease team and referring to local antibiogram patterns of each NICU is also warranted. It is worth mentioning that emerging studies show that shorter durations of antibiotics might be as effective as longer durations and can reduce changes in the emergence of antimicrobial resistance [ 66 , 67 ]. Lewald et al. performed prospective surveillance of infants diagnosed with pneumonia and sterile blood culture receiving a five-day course of antibiotics where 14% of their cohort were infants ≤37 weeks. Their study revealed that only 3% of their cohort had antibiotics restarted after five days for relapsed pneumonia. Three infants died within 14 days of antibiotic discontinuation from Pseudomonas sepsis, and one infant died from Klebsiella sepsis due to necrotizing enterocolitis NEC [ 68 ]. The significance of this study is that it shows the potential for shorter course treatment. However, further studies in premature neonates need to be conducted.

The four studies on the periphery depict the most commonly cited studies on the effectiveness of VAP bundles. In the center, we list the measures widely used by NICUs as a part of VAP bundles [ 73 , 74 , 75 , 76 ].

Prevention of VAP is accomplished by avoiding prolonged IMV. Removing the ETT when possible is critical in preventing VAP and should be a focus of everyday clinical decision-making. The CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) recommends using orotracheal tubes and changing respiratory circuits only for malfunction or contamination. There is no recommendation for routine exchange of ETTs or circuits without any clinical indication [ 69 ].

Hand hygiene is an important strategy to prevent nosocomial infections such as VAP. In a study in which alcohol-based hand gels were used for hand hygiene, a reduction of neo-VAP was shown in VLBW neonates [ 70 ]. In another study of NICU patients, increased compliance with hand hygiene reduced the incidence of respiratory infections from 3.35 to 1.06 per 1000 patient days [ 71 ]. Suctioning of the endotracheal tube is done to clear airway secretions. No specific recommendations on types or frequency of airway suctioning have been shown to decrease the incidence of neo-VAP for neonates. Cordero et al. have shown no difference between open and closed suctioning in neonates regarding VAP incidence or mortality, even though it seems logical that a closed system should be helpful [ 72 ].

Studies on VAP in neonates focusing on prevention are limited to quality improvement projects and generally focus on implementing multiple-item bundles (Fig.  4 ). Azab et al. performed a prospective observational cohort study of 143 neonates, implementing a bundle that included frequent assessment for extubation readiness, hand hygiene, oral hygiene, positioning, closed sterile suctioning, strict reintubation guidelines, and changing the ventilator circuit every seven days. Their bundle showed a significantly decreased incidence of neo-VAP from 36.4 to 23 cases per 1000 IMV days ( P  = 0.0006) [ 73 ]. Jacobs Pepin et al. enforced a similar NICU bundle with the addition of guidelines on disinfecting the patient environment and draining condensation from ventilator tubing when suctioning and showed a decrease in the incidence of neo-VAP from 8.5 to 2.5 cases per 1000 ventilator days ( P  < 0.004) [ 74 ]. Ceballos et al. demonstrated that in addition to the common interventions for the prevention of hospital-acquired infection in the NICU, replacing the circuit with reintubation, ensuring a sterile field upon intubation, frequent endotracheal tube positioning, a protocol for weaning off the ventilator decreased their incidence of neo-VAP from 8.9 to 3.9 cases per 1000 vent days in neonates <750 g [ 75 ]. Lastly, a prospective cohort study by Pinilla-Gonzales et al. introducing a similar bundle with the addition of sterile airway management and feeds running for 60–120 min as opposed to bolus or continuous feeds showed a decrease of VAP incidence from 11.7 to 1.9 cases per 1000 ventilator days ( P  < 0.01) [ 76 ].

Flowsheet for the neonatal provider at the bedside to aid in diagnosing and managing VAP in the neonate based on CDC guidelines and published studies and modified from Goerens et al. Front Pediatr 2018 [ 5 ].

Elevating the head of the bed is a part of some neo-VAP prevention bundles. This originated from adult literature proposing that VAP is associated with supine patient positioning, which promotes gastroesophageal reflux with subsequent aspiration. Gastric content refluxing into the airway is believed to increase the risk of VAP, as gastrointestinal pathogens can colonize the airway. However, head of bed elevation is against safe sleep recommendations by the American Academy of Pediatrics. Bagucka et al. showed that head-of-bed elevation can promote reflux in term infants compared with supine positioning [ 77 , 78 ]. In the pediatric literature, there is no significant difference in VAP incidence between patients who receive H2-blocker prophylaxis compared to patients who did not [ 79 ]. In addition, the use of histamine H2-receptor antagonists (H2-blockers, e.g., ranitidine) in neonates is controversial since recent studies have shown that the use of H2-blockers could be associated with NEC, sepsis, osteoporosis, and intraventricular hemorrhage [ 80 ].

Several other VAP preventive measures include using bacteriostatic nanotechnology-coated ETTs and probiotics. In adults, bacteriostatic nanotechnology coating can be used on the ETT to prevent biofilm formation. However, this has not been studied in the neonatal population, and efforts are underway to adapt this technology potentially [ 81 ]. Sun et al. performed a systematic review and meta-analysis in adults, children, and neonates on the efficacy and safety of probiotics in preventing VAP. It showed evidence to suggest that prophylactic probiotics could help prevent VAP [ 82 ]. In one large Level IV NICU, placement of ultra-violet germicidal irradiation into the heating-ventilation-air conditioning circuit significantly decreased the VAP rate [ 83 ]. There is also evidence that oropharyngeal colostrum could significantly reduce VAP and NEC [ 84 ]. Lastly, there is emerging evidence for using nebulized hypertonic saline for airway clearance. A small cohort study in premature infants showed that nebulized hypertonic saline decreases VAP occurrence [ 85 ].

Neo-VAP is a challenging diagnosis given the current CDC definitions that are not specific to neonates, especially preterm neonates, who constitute most of the neo-VAP burden. The diagnosis and management of VAP have progressed minimally over the last decade despite medical and technological advancements in neonatology. There are few sensitive or specific markers for diagnosing pulmonary infection in neonates apart from culture, which has the challenge of separating invasive infection from colonization. Newer biomarkers such as procalcitonin and presepsin have been described but not proven superior to ETT culture. Differentiating colonization and infection presents a significant challenge for neonatologists in a baby with persistent radiographic infiltrates. It often leads to overuse of antibiotics, leading to the emergence of further antibiotic-resistant strains. There is a growing repertoire of VAP prevention bundles and emerging non-antibiotic prophylactic medications. However, there is still a need for better, earlier, and more definitive diagnoses, treatment, and prevention options for neo-VAP, given the associations with increased morbidity and mortality, as well as the contribution to increased length of stay and healthcare costs.

Miller JD, Carlo WA. Pulmonary complications of mechanical ventilation in neonates. Clin Perinatol. 2008;35:273–81. x-xi

Article   PubMed   Google Scholar  

Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU]) Event. 2023.

Thatrimontrichai A, Rujeerapaiboon N, Janjindamai W, Dissaneevate S, Maneenil G, Kritsaneepaiboon S, et al. Outcomes and risk factors of ventilator-associated pneumonia in neonates. World J Pediatr. 2017;13:328–34.

Cernada M, Brugada M, Golombek S, Vento M. Ventilator-associated pneumonia in neonatal patients: an update. Neonatology. 2014;105:98–107.

Goerens A, Lehnick D, Buttcher M, Daetwyler K, Fontana M, Genet P, et al. Neonatal ventilator associated pneumonia: a quality improvement initiative focusing on antimicrobial stewardship. Front Pediatr. 2018;6:262.

Article   PubMed   PubMed Central   Google Scholar  

Donowitz LG. Nosocomial infection in neonatal intensive care units. Am J Infect Control. 1989;17:250–7.

Article   CAS   PubMed   Google Scholar  

Harpin VA, Rutter N. Barrier properties of the newborn infant’s skin. J Pediatr. 1983;102:419–25.

Carr R, Modi N. Haemopoietic colony stimulating factors for preterm neonates. Arch Dis Child Fetal Neonatal Ed. 1997;76:F128–33.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Kohler PF, Farr RS. Elevation of cord over maternal IgG immunoglobulin: evidence for an active placental IgG transport. Nature. 1966;210:1070–1.

Looi K, Evans DJ, Garratt LW, Ang S, Hillas JK, Kicic A, et al. Preterm birth: born too soon for the developing airway epithelium? Paediatr Respir Rev. 2019;31:82–8.

PubMed   Google Scholar  

Berdal JE, Bjornholt J, Blomfeldt A, Smith-Erichsen N, Bukholm G. Patterns and dynamics of airway colonisation in mechanically-ventilated patients. Clin Microbiol Infect. 2007;13:476–80.

Tan B, Zhang F, Zhang X, Huang YL, Gao YS, Liu X, et al. Risk factors for ventilator-associated pneumonia in the neonatal intensive care unit: a meta-analysis of observational studies. Eur J Pediatr. 2014;173:427–34.

Oami T, Chihade DB, Coopersmith CM. The microbiome and nutrition in critical illness. Curr Opin Crit Care. 2019;25:145–9.

Martin-Loeches I, Dickson R, Torres A, Hanberger H, Lipman J, Antonelli M, et al. The importance of airway and lung microbiome in the critically ill. Crit Care. 2020;24:537.

Li H, Song C, Liu D, Ai Q, Yu J. Molecular analysis of biofilms on the surface of neonatal endotracheal tubes based on 16S rRNA PCR-DGGE and species-specific PCR. Int J Clin Exp Med. 2015;8:11075–84.

CAS   PubMed   PubMed Central   Google Scholar  

Wagner BD, Sontag MK, Harris JK, Miller JI, Morrow L, Robertson CE, et al. Prenatal complications are associated with the postnatal airway host response and microbiota in intubated preterm infants. J Matern Fetal Neonatal Med. 2019;32:1499–506.

Friedland DR, Rothschild MA, Delgado M, Isenberg H, Holzman I. Bacterial colonization of endotracheal tubes in intubated neonates. Arch Otolaryngol Head Neck Surg. 2001;127:525–8.

Farhath S, Aghai ZH, Nakhla T, Saslow J, He Z, Soundar S, et al. Pepsin, a reliable marker of gastric aspiration, is frequently detected in tracheal aspirates from premature ventilated neonates: relationship with feeding and methylxanthine therapy. J Pediatr Gastroenterol Nutr. 2006;43:336–41.

Lopriore E, Markhorst DG, Gemke RJ. Ventilator-associated pneumonia and upper airway colonisation with Gram negative bacilli: the role of stress ulcer prophylaxis in children. Intensive Care Med. 2002;28:763–7.

Albert BD, Zurakowski D, Bechard LJ, Priebe GP, Duggan CP, Heyland DK, et al. Enteral Nutrition and Acid-Suppressive Therapy in the PICU: Impact on the Risk of Ventilator-Associated Pneumonia. Pediatr Crit Care Med. 2016;17:924–9.

Rouze A, Jaillette E, Nseir S. Relationship between microaspiration of gastric contents and ventilator-associated pneumonia. Ann Transl Med. 2018;6:428.

Alriyami A, Kiger JR, Hooven TA. Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit. Neoreviews. 2022;23:e448–e61.

El Abiad MT RA, Nader N, Yu W, Lakshminrusimha S, Kumar VH, Blessing-Hanagan K, et al. Tracheal pepsin activity in intubated very low birth weight (VLBW) infants. Pediatric Acad Soc 2006.

Prescott HC, O’Brien JM. Prevention of ventilator-associated pneumonia in adults. F1000 Med Rep. 2010;2:15.

Garland JS. Strategies to prevent ventilator-associated pneumonia in neonates. Clin Perinatol. 2010;37:629–43.

Feldman C, Kassel M, Cantrell J, Kaka S, Morar R, Goolam Mahomed A, et al. The presence and sequence of endotracheal tube colonization in patients undergoing mechanical ventilation. Eur Respir J. 1999;13:546–51.

Pan Y, Song S, Tang X, Ai Q, Zhu D, Liu Z, et al. Streptococcus sp. in neonatal endotracheal tube biofilms is associated with ventilator-associated pneumonia and enhanced biofilm formation of Pseudomonas aeruginosa PAO1. Sci Rep. 2017;7:3423.

Ventilator-Associated Event (VAE). National Healthcare Safety Network, Centers for Disease Control and Prevention.

Tripathi S MG, Jain A, Kohli N. Study of ventilator associated pneumonia in neonatal intensive care unit: characteristics, risk factors and outcome. Internet J Med Update-EJOURNAL. 2010;5:12–19.

Morris AC, Kefala K, Simpson AJ, Wilkinson TS, Everingham K, Kerslake D, et al. Evaluation of the effect of diagnostic methodology on the reported incidence of ventilator-associated pneumonia. Thorax. 2009;64:516–22.

Dancer SJ, Coyne M, Robertson C, Thomson A, Guleri A, Alcock S. Antibiotic use is associated with resistance of environmental organisms in a teaching hospital. J Hosp Infect. 2006;62:200–6.

Langston SJ, Pithia N, Sim MS, Garg M, de St Maurice A, Chu A. Lack of utility of tracheal aspirates in the management of suspected pneumonia in intubated neonates. Infect Control Hosp Epidemiol. 2020;41:660–5.

Cernada M, Aguar M, Brugada M, Gutierrez A, Lopez JL, Castell M, et al. Ventilator-associated pneumonia in newborn infants diagnosed with an invasive bronchoalveolar lavage technique: a prospective observational study. Pediatr Crit Care Med. 2013;14:55–61.

Liao CC, Tsai MH, Lai SH, Lai MY, Chu SM, Huang HR, et al. Safety and clinical application of nonbronchoscopic bronchoalveolar lavage in preterm neonates with clinical ventilator-associated pneumonia. Pediatr Neonatol. 2021;62:195–201.

Dell’Orto V, Bourgeois-Nicolaos N, Rouard C, Romain O, Shankar-Aguilera S, Doucet-Populaire F, et al. Cell Count Analysis from Nonbronchoscopic Bronchoalveolar Lavage in Preterm Infants. J Pediatr. 2018;200:30–7.e2.

D’Angio CT, Maniscalco WM, Ryan RM, Avissar NE, Basavegowda K, Sinkin RA. Vascular endothelial growth factor in pulmonary lavage fluid from premature infants: effects of age and postnatal dexamethasone. Biol Neonate. 1999;76:266–73.

LoMonaco MB, Barber CM, Sinkin RA. Differential cytokine mRNA expression by neonatal pulmonary cells. Pediatr Res. 1996;39:248–52.

Mourani PM, Harris JK, Sontag MK, Robertson CE, Abman SH. Molecular identification of bacteria in tracheal aspirate fluid from mechanically ventilated preterm infants. PLoS One. 2011;6:e25959.

Fritz CQ, Edwards KM, Self WH, Grijalva CG, Zhu Y, Arnold SR, et al. Prevalence, risk factors, and outcomes of bacteremic pneumonia in children. Pediatrics. 2019;144.e20183090

Apisarnthanarak A, Holzmann-Pazgal G, Hamvas A, Olsen MA, Fraser VJ. Ventilator-associated pneumonia in extremely preterm neonates in a neonatal intensive care unit: characteristics, risk factors, and outcomes. Pediatrics. 2003;112:1283–9.

Wang HC, Tsai MH, Chu SM, Liao CC, Lai MY, Huang HR, et al. Clinical characteristics and outcomes of neonates with polymicrobial ventilator-associated pneumonia in the intensive care unit. BMC Infect Dis. 2021;21:965.

Kaufman D, Fairchild KD. Clinical microbiology of bacterial and fungal sepsis in very-low-birth-weight infants. Clin Microbiol Rev. 2004;17:638–80.

Pradeepkumar VK, Rajadurai VS, Tan KW. Congenital candidiasis: varied presentations. J Perinatol. 1998;18:311–6.

CAS   PubMed   Google Scholar  

Jain S, Gautam V, Naseem S. Acute-phase proteins: as diagnostic tool. J Pharm Bioallied Sci. 2011;3:118–27.

Badr MA, Ali YF, Albanna EA, Beshir MR, Amr GE. Ventilator associated pneumonia in critically-ill neonates admitted to neonatal intensive care unit, zagazig university hospitals. Iran J Pediatr. 2011;21:418–24.

PubMed   PubMed Central   Google Scholar  

Katayama Y, Minami H, Enomoto M, Takano T, Hayashi S, Lee YK. Usefulness of Gram staining of tracheal aspirates in initial therapy for ventilator-associated pneumonia in extremely preterm neonates. J Perinatol. 2010;30:270–4.

Povoa P, Martin-Loeches I, Ramirez P, Bos LD, Esperatti M, Silvestre J, et al. Biomarker kinetics in the prediction of VAP diagnosis: results from the BioVAP study. Ann Intensive Care. 2016;6:32.

Fattah MA, Omer AF, Asaif S, Manlulu R, Karar T, Ahmed A, et al. Utility of cytokine, adhesion molecule and acute phase proteins in early diagnosis of neonatal sepsis. J Nat Sci Biol Med. 2017;8:32–9.

Brown JVE, Meader N, Wright K, Cleminson J, McGuire W. Assessment of C-reactive protein diagnostic test accuracy for late-onset infection in newborn infants: a systematic review and meta-analysis. JAMA Pediatr. 2020;174:260–8.

Chesney RW, McCarron DM, Haddad JG, Hawker CD, DiBella FP, Chesney PJ, et al. Pathogenic mechanisms of the hypocalcemia of the staphylococcal toxic-shock syndrome. J Lab Clin Med. 1983;101:576–85.

Downes KJ, Fitzgerald JC, Weiss SL. Utility of procalcitonin as a biomarker for sepsis in children. J Clin Microbiol. 2020;58:e01851–19.

McWilliam S, Riordan A. How to use: C-reactive protein. Arch Dis Child Educ Pr Ed. 2010;95:55–8.

Article   CAS   Google Scholar  

Zhao X, Xu L, Yang Z, Sun B, Wang Y, Li G, et al. Significance of sTREM-1 in early prediction of ventilator-associated pneumonia in neonates: a single-center, prospective, observational study. BMC Infect Dis. 2020;20:542.

Nandan D, Nimesh M, Kumar S, Manik L, Sudarshan J, Duggal N. Serum procalcitonin as an early inflammatory marker in pediatric ventilator-associated pneumonia: A prospective observational study. J Pediatr Crit Care. 2021;8:229–33.

Article   Google Scholar  

Eschborn S, Weitkamp JH. Procalcitonin versus C-reactive protein: review of kinetics and performance for diagnosis of neonatal sepsis. J Perinatol. 2019;39:893–903.

Yaegashi Y, Shirakawa K, Sato N, Suzuki Y, Kojika M, Imai S, et al. Evaluation of a newly identified soluble CD14 subtype as a marker for sepsis. J Infect Chemother. 2005;11:234–8.

Poggi C, Lucenteforte E, Petri D, De Masi S, Dani C. Presepsin for the diagnosis of neonatal early-onset sepsis: a systematic review and meta-analysis. JAMA Pediatr. 2022;176:750–8.

Savic D, Simovic A, Markovic S, Kostic G, Vuletic B, Radivojevic S, et al. The role of presepsin obtained from tracheal aspirates in the diagnosis of early onset pneumonia in intubated newborns. Indian J Pediatr. 2018;85:968–73.

Tusor N, De Cunto A, Basma Y, Klein JL, Meau-Petit V. Ventilator-associated pneumonia in neonates: the role of point of care lung ultrasound. Eur J Pediatr. 2021;180:137–46.

Raycheva R, Rangelova V, Kevorkyan A. Cost analysis for patients with ventilator-associated pneumonia in the neonatal intensive care unit. Healthcare (Basel). 2022;10:980.

Dell’Orto V, Raschetti R, Centorrino R, Montane A, Tissieres P, Yousef N, et al. Short- and long-term respiratory outcomes in neonates with ventilator-associated pneumonia. Pediatr Pulmonol. 2019;54:1982–8.

Wang HC, Liao CC, Chu SM, Lai MY, Huang HR, Chiang MC, et al. Impacts of multidrug-resistant pathogens and inappropriate initial antibiotic therapy on the outcomes of neonates with ventilator-associated pneumonia. Antibiotics (Basel). 2020;9:760.

Korang SK, Safi S, Gluud C, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for neonatal sepsis - a protocol for a systematic review with meta-analysis. Syst Rev. 2019;8:306.

Nakwan N, Wannaro J, Thongmak T, Pornladnum P, Saksawad R, Nakwan N, et al. Safety in treatment of ventilator-associated pneumonia due to extensive drug-resistant Acinetobacter baumannii with aerosolized colistin in neonates: a preliminary report. Pediatr Pulmonol. 2011;46:60–6.

Hussain K, Salat MS, Ambreen G, Mughal A, Idrees S, Sohail M, et al. Intravenous vs intravenous plus aerosolized colistin for treatment of ventilator-associated pneumonia - a matched case-control study in neonates. Expert Opin Drug Saf. 2020;19:1641–9.

Mathur NB, Murugesan A. Comparison of four days versus seven days duration of antibiotic therapy for neonatal pneumonia: a randomized controlled trial. Indian J Pediatr. 2018;85:963–7.

Engle WD, Jackson GL, Sendelbach D, Ford D, Olesen B, Burton KM, et al. Neonatal pneumonia: comparison of 4 vs 7 days of antibiotic therapy in term and near-term infants. J Perinatol. 2000;20:421–6.

Lewald ZS, Prusakov P, Magers JK, Kielt MJ, de Alba Romero C, White NO, et al. Short-course antibiotic therapy for pneumonia in the neonatal intensive care unit. J Perinatol. 2023;43:1145–51.

Tablan, Anderson OC, Besser LJ, Bridges R, Hajjeh C, Cdc R, et al. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53:1–36.

Rogers E, Alderdice F, McCall E, Jenkins J, Craig S. Reducing nosocomial infections in neonatal intensive care. J Matern Fetal Neonatal Med. 2010;23:1039–46.

Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, Tsou KI, et al. Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol. 2004;25:742–6.

Cordero L, Sananes M, Ayers LW. Comparison of a closed (Trach Care MAC) with an open endotracheal suction system in small premature infants. J Perinatol. 2000;20:151–6.

Azab SF, Sherbiny HS, Saleh SH, Elsaeed WF, Elshafiey MM, Siam AG, et al. Reducing ventilator-associated pneumonia in neonatal intensive care unit using “VAP prevention Bundle”: a cohort study. BMC Infect Dis. 2015;15:314.

Jacobs Pepin B, Lesslie D, Berg W, Spaulding AB, Pokora T. ZAP-VAP: A Quality Improvement Initiative to Decrease Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit, 2012-2016. Adv Neonatal Care. 2019;19:253–61.

Ceballos K, Waterman K, Hulett T, Makic MB. Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. Adv Neonatal Care. 2013;13:154–63.

Pinilla-Gonzalez A, Solaz-Garcia A, Parra-Llorca A, Lara-Canton I, Gimeno A, Izquierdo I, et al. Preventive bundle approach decreases the incidence of ventilator-associated pneumonia in newborn infants. J Perinatol. 2021;41:1467–73.

Bagucka B, De Schepper J, Peelman M, Van de Maele K, Vandenplas Y. Acid gastro-esophageal reflux in the 10 degrees-reversed-Trendelenburg-position in supine sleeping infants. Acta Paediatr Taiwan. 1999;40:298–301.

Goodstein MH, Stewart DL, Keels EL, Moon RY, Committee On F, Newborn TFOSIDS. Transition to a Safe Home Sleep Environment for the NICU Patient. Pediatrics. 2021;148:e2021052045.

Slaughter JL, Stenger MR, Reagan PB, Jadcherla SR. Neonatal histamine-2 receptor antagonist and proton pump inhibitor treatment at United States children’s hospitals. J Pediatr. 2016;174:63–70.e3.

Reinhart RM, McClary JD, Zhang M, Marasch JL, Hibbs AM, Nock ML. Reducing antacid use in a level IV NICU: A QI project to reduce morbidity. Pediatr Qual Saf. 2020;5:e303.

Machado MC, Cheng D, Tarquinio KM, Webster TJ. Nanotechnology: pediatric applications. Pediatr Res. 2010;67:500–4.

Sun YC, Wang CY, Wang HL, Yuan Y, Lu JH, Zhong L. Probiotic in the prevention of ventilator-associated pneumonia in critically ill patients: evidence from meta-analysis and trial sequential analysis of randomized clinical trials. BMC Pulm Med. 2022;22:168.

Ryan RM, Wilding GE, Wynn RJ, Welliver RC, Holm BA, Leach CL. Effect of enhanced ultraviolet germicidal irradiation in the heating ventilation and air conditioning system on ventilator-associated pneumonia in a neonatal intensive care unit. J Perinatol. 2011;31:607–14.

Ma A, Yang J, Li Y, Zhang X, Kang Y. Oropharyngeal colostrum therapy reduces the incidence of ventilator-associated pneumonia in very low birth weight infants: a systematic review and meta-analysis. Pediatr Res. 2021;89:54–62.

Ezzeldin Z, Mansi Y, Gaber M, Zakaria R, Fawzy R, Mohamed MA. Nebulized hypertonic saline to prevent ventilator associated pneumonia in premature infants, a randomized trial. J Matern Fetal Neonatal Med. 2018;31:2947–52.

Adivitiya, Kaushik MS, Chakraborty S, Veleri S, Kateriya S. Mucociliary Respiratory Epithelium Integrity in Molecular Defense and Susceptibility to Pulmonary Viral Infections. Biology (Basel). 2021;10:95.

Kumar V. Pulmonary Innate Immune Response Determines the Outcome of Inflammation During Pneumonia and Sepsis-Associated Acute Lung Injury. Front Immunol. 2020;11:1722.

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Dayle J. Bondarev, Rita M. Ryan & Devashis Mukherjee

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Bondarev, D.J., Ryan, R.M. & Mukherjee, D. The spectrum of pneumonia among intubated neonates in the neonatal intensive care unit. J Perinatol (2024). https://doi.org/10.1038/s41372-024-01973-9

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Received : 28 February 2023

Revised : 17 February 2024

Accepted : 15 April 2024

Published : 02 May 2024

DOI : https://doi.org/10.1038/s41372-024-01973-9

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