Influence of changing endotracheal tube cuff management on antibiotic use for ventilator-associated pneumonia in a tertiary intensive care unit

Authors:

• Darvall, Jai N.
• Thevarajan, Irani
• Iles, Simon
• Rechnitzer, Thomas
• Spelman, Tim
• Harley, Nerina

Details:

Critical Care and Resuscitation, Volume 19, Issue 3, 2017-09-30

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Background: Routine deflation of the endotracheal tube (ETT) cuff of critically ill patients receiving MV is common in Australia and New Zealand. Literature about ventilator-associated pneumonia (VAP) and antibiotic use rates with different ETT cuff maintenance practices is lacking. Objective: To determine the impact of a change in ETT cuff maintenance from a minimal leak technique to pressure manometry on the administration of antibiotics for VAP. Design, setting and participants: A prospective, pre–post observational study conducted in a metropolitan tertiary referral intensive care unit. We analysed data from 178 patients receiving MV for > 48 hours during 13 weeks of minimal leak test ETT cuff technique (pre-intervention, n = 92) or 13 weeks of cuff pressure manometry (postintervention, n = 86), separated by 3 weeks’ “wash-out”. Main outcome measures: Primary outcome was the number of patients receiving antibiotics for the indication of VAP. Secondary outcomes were incidence of ventilator-associated surveillance events, lengths of stay (LOSs) and mortality. Results: Antibiotics were administered for VAP in 24 patients (26.1%) in the pre-intervention period compared with 11 post-intervention patients (12.8%). The univariate antibiotic administraion rate per 100 ventilation days was 15.3% (95% CI, 12.6%–18.4%) v 6.8% (95% CI, 4.9%–9.3%), and the incident rate ratio (IRR) was 0.45 (95% CI, 0.31–0.64); P < 0.001). After adjustment for ventilation duration, IRR was 0.55 (95% CI, 0.24–1.27); P = 0.160. The ventilator-associated complication incidence rate was lower in the post-intervention group (11.4% v 16.3%; IRR, 0.70 [95% CI, 0.51–0.95]; P = 0.018). After adjustment for duration of MV, IRR was 0.66 (95% CI, 0.25–1.70); P = 0.387. Antibiotic administration for VAP was associated with increased ICU and hospital LOSs, but not with mortality. Conclusions: ETT cuff pressure manometry is associated with a reduced rate of antibiotic administration for a diagnosis of VAP compared with a minimal leak test technique.