Scandinavian Journal of Infectious Diseases, 2011; 43: 243250

REVIEW ARTICLE

Infection prevention in the intensive care unit: Review of the recent literature on the management of invasive devices

ALESSANDRO DI FILIPPO, ANDREA CASINI & ANGELO RAFFAELE DE GAUDIO

From the Department of Critical Care, Section of Anaesthesia, University of Florence, Florence, Italy

Abstract Over the last 5 y, clinical trials investigating products, procedures, and treatments aimed at preventing infections in the intensive care unit have been described. The ndings of these studies appear to conrm the effectiveness of certain preventive procedures. With regard to ventilator-associated pneumonia, the efcacies of decontamination of the oral cavity, continuous suction of subglottic secretions, positioning of the patient, selective decontamination of the digestive tract, and (for higher-risk patients) endotracheal tubes coated with silver, have been demonstrated. Medicated catheters and chlorhexidinebased dressings have been found useful for catheter-related bloodstream infections, and medical catheters have also been shown to be efcacious against urinary tract infections. All these procedures can be incorporated into departmental protocols for the prevention of nosocomial infections in the intensive care unit. Keywords: Infection prevention, pneumonia, hospital, blood stream infection, catheter, urinary tract infection, bladder

catheter

Introduction This review presents a summary of studies conducted over the last 5 y investigating the efcacy of the management of invasive devices in the prevention of infections in intensive care units (ICUs), in particular ventilator-associated pneumonia (VAP), catheterrelated bloodstream infections (CRBSI), and catheter-associated urinary tract infections (UTI). A summary table is provided, describing the most recent interventions and their effectiveness (Table I).

Ventilator-associated pneumonia (VAP) The 2004 US Centers for Disease Control and Prevention (CDC) guidelines for the prevention of VAP indicate the existence of fundamental principles that possess level 1-A evidence [1]. These fundamental principles include the education of all workers in health epidemiology and VAP control procedures. The guidelines advise the thorough cleaning of all ventilator and circuit equipment; contaminated hands should be washed frequently and thoroughly

with water and soap (antimicrobial or not) or an alcoholic antiseptic solution; moreover, it is good practice to remove all devices such as endotracheal tubes and tracheostomy tubes when clinical indications no longer exist. In the last 5 y, clinical trials have been undertaken to investigate the main methods of VAP prevention. The major results from these trials are discussed below. Poor oral hygiene in patients undergoing mechanical ventilation is often associated with secondary colonization of the respiratory tract, leading to the subsequent development of pneumonia. This observation implies that proper hygiene will reduce VAP incidence, as conrmed by a large clinical trial [2] and meta-analysis [3]; ultimately, it should reduce mortality in the ICU [4]. Multiple strategies are used for decontamination of the oral cavity. For example, Panchabhai et al. compared chlorhexidine 0.2% with a control solution of 0.01% potassium permanganate in a prospective randomized trial [5]. Oral cleansing was performed twice daily on 512 patients admitted to

Correspondence: A. Di Filippo, Department of Critical Care, Section of Anaesthesia, University of Florence, c/o Careggi Teaching Hospital, V. le Morgagni 85, Firenze 50124, Italy. Tel: 39 055 434807. Fax: 39 055 430393. E-mail: adilippo@uni.it (Received 26 October 2010 ; accepted 29 December 2010 ) ISSN 0036-5548 print/ISSN 1651-1980 online 2011 Informa Healthcare DOI: 10.3109/00365548.2011.552070

244

A. D. Filippo et al.

Table I. Recent advances in prevention of intensive care infections related to the management of invasive devices. Method Ventilator-associated pneumonia Decontamination of the oral cavity Contents of the study Efcacy Reference

Removal of endotracheal secretions

Generic oral care Chlorhexidine 0.2% vs potassium permanganate Chlorhexidine 2% colistin 2% vs chlorhexidine 2% vs saline Chlorhexidine 2% vs saline Chlorhexidine (0.2%) gel Povidone iodine vs saline Electric toothbrush vs chlorhexidine Washing with isotonic saline Closed tracheal suction system vs open system Polyurethane vs polyvinyl chloride tube Polyurethane cuff and subglottic suction tube vs polyvinyl tube with no subglottic suction Automatic Heated humidier vs heat and moisture exchangers Heated humidier vs heat and moisture exchangers in prolonged ventilation Early tracheostomy Prophylactic PEEP Prone position Kinetic bed

Effective Not effective Effective Effective Not effective Effective Not effective Effective Not effective Effective Effective Effective

[2], [3] [5] [5], [6] [7] [8] [9] [10] [11] [12], [13], [14] [15], [16], [17] [18] [19]

Subglottic continuous suction Materials

Cuff inating control Silver-coated endotracheal tube Humidication device

Not effective Effective Not effective Effective Not effective Effective Not effective Effective with doubt Effective Effective

[20] [21] [22], [23], [25] [19] [26], [27] [28] [29], [30] [31] [32], [33] [34]

Tracheostomy Mechanical ventilation mode Patient positioning

Selective decontamination of the digestive tract Non invasive ventilation Catheter-related blood stream infection Medicated catheters

Catheter tunnelling Site chosen Medication

Removal of catheter as soon as possible Selective decontamination of digestive tract Urinary tract infection Medicated catheters

Catheters with silverplatinumcarbon vs catheters with rifampicinminocycline Catheters with chlorhexidine and sulfadiazine vs standard catheters Silver-impregnated vs standard multilumen catheters Long stay medicated catheter vs tunnelled catheter Jugular vs. femoral Chlorhexidine vs povidone iodine alcohol Chlorhexidine for daily hygiene Chlorhexidine impregnated wipes Chlorhexidine impregnated dressing Reminder in daily sheet

Effective but not different Effective Not effective Effective Not effective Effective Effective Effective Effective Effective Effective on overall and Gram-neg BSI

[36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46]

Antibiotic prophylaxis

Nitrofurazone-impregnated vs silicone catheters Hydrophilic catheters Trimethoprimsulfamethoxazole in 3 doses

Effective Not effective Effective

[48] [49] [50]

PEEP, positive end-expiratory pressure; BSI, blood stream infection.

Infection prevention in the intensive care unit ICUs. Statistical analysis indicated that the VAP incidence was not correlated with the performance of oral cleansing using chlorhexidine or potassium permanganate. Mortality, seen as a secondary outcome, occurred at a rate of 34.8% in chlorhexidine-treated patients and 28.3% in the control group. However, the VAP incidence was lower (7.4%) at 3 months after treatment compared to 3 months before (21.7%), regardless of treatment type. Koeman et al. conducted a randomized doubleblind trial of 385 patients divided into 3 groups: 130 placebo-treated patients, 127 patients treated with chlorhexidine 2%, and 128 patients treated with colistin chlorhexidine 2% 2% [6]. The daily risk of VAP was reduced in both treatment groups compared with the placebo group: 65% (hazard ratio (HR) 0.352, 95% condence interval (CI) 0.1600.791; p 0.012) for chlorhexidine and 55% (HR 0.454, 95% CI 0.2240. 925; p 0.030) for colistin chlorhexidine. The combination of colistin with chlorhexidine resulted in a signicant reduction in colonization by Grampositive and Gram-negative endotracheal and oral microorganisms [6]. In a randomized controlled trial on 207 patients receiving mechanical ventilation, Tantipong et al. observed a reduction in the rate of pneumonia in the group using 2% chlorhexidine compared with the placebo group [7]. However, in a multicenter prospective doubleblind trial conducted in 228 patients undergoing mechanical ventilation for at least 5 days, oral chlorhexidine (0.2%) gel decontamination was not associated with signicant decreases in VAP incidence, duration of hospitalization, or mortality, nor was it effective against multi-resistant microorganisms (Pseudomonas aeruginosa, Acinetobacter, Enterobacteriaceae) [8]. The conclusion to be drawn from these studies is that the concentration of disinfectant is critical in achieving effective prevention; therefore a study on a large number of patients should be done to verify this difference. The use of povidoneiodine for oral decontamination appears to be related to a reduction in the development of secondary infections. Regular use of povidoneiodine was found to be associated with a signicant reduction in the incidence of VAP in a prospective randomized study conducted on 98 patients with severe head trauma who had undergone mechanical ventilation for at least 48 h [9]. In this study, 36 patients were treated with povidoneiodine, 31 patients with saline, and the rest were treated with simple aspiration of secretions; VAP incidence was 8% in the rst group, 39% in the second group, and 42% in the third group. There were no statistically signicant differences in the duration of hospitalization or mortality in the ICU among the groups [9].

245

Effective reduction of VAP as a result of the use of electric toothbrushes remains controversial. In a recent prospective trial conducted on 147 patients intubated for more than 48 h, Pobo et al. demonstrated that the use of electric toothbrushes did not signicantly reduce the development of VAP compared with 0.12% chlorhexidine oral cleansing [10]. Removal of endotracheal secretions appears to be a primary step in preventing VAP and can be carried out continuously or at scheduled intervals. Periodic aspiration of secretions after instillation of isotonic saline seems to reduce VAP incidence in patients with tracheotomies. A randomized trial of 262 patients admitted to ICUs revealed that VAP incidence was signicantly lower in a group of patients in whom aspiration was performed following the administration of isotonic saline (23.5% vs 10.8%, p 0.008) with a relative risk (RR) of 54% (95% CI 1874%). However, the incidence of atelectasis and obstruction of the endotracheal tube was similar in both groups [11]. The aspiration of secretions can be performed with closed or open systems. No signicant difference in VAP prevention was found in a randomized study of 443 patients, 210 treated with a closed tracheal suction system and 233 with an open system [12]. Similar negative results were then published by the same authors [13] and conrmed by a large meta-analysis (8 studies, 1272 patients) the following year [14]. In contrast, continuous aspiration of subglottic secretions was found to be effective in reducing the use of antimicrobial agents and the incidence of VAP in patients undergoing cardiac surgery [15]. In another recent study on 333 mechanically ventilated patients, an intermittent aspiration of subglottic secretions was effective in reducing the incidence of early- and late-onset VAP, yielding a RR reduction of 42.2% [16]. These studies conrmed the results of a preceding meta-analysis of 5 studies and 896 patients, which stated that the use of aspiration of subglottic secretions reduced the incidence of early VAP by nearly half [17]. For patients undergoing mechanical ventilation via endotracheal tube placement, special attention must be paid to the material used to build the device and the integrity of the structures of the device itself. These patients experience an increased risk of nosocomial pneumonia, and micro-subglottic contaminated secretions are among the leading causes of VAP. A polyurethane-cuffed tube may be able to prevent the onset of VAP. For example, in a study of 134 post-cardiac surgery patients, Poelaert et al. showed that the incidence of pneumonia during early postoperative mechanical ventilation was signicantly

246

A. D. Filippo et al. Evidence also exists to the contrary. In fact Blot et al., in a group of 123 patients submitted to early tracheostomy (n 61) or prolonged intubation (n 62), failed to demonstrate a difference in the incidence of VAP in the 2 groups of patients [26]. Furthermore, early tracheostomy (within 8 days) in a small group (60 total) of trauma patients was not able to reduce the duration of ventilation, frequency of pneumonia, or ICU hospitalization compared to a control group in which the tracheostomy was performed 28 days or more after the acute event [27]. The mode of mechanical ventilation also appears to play a role in the prevention of VAP, but the use of positive end-expiratory pressure (PEEP) seems to be an issue. The effectiveness of PEEP was recently studied in 131 mechanically ventilated patients, with chest radiographs and a Horowitz index 250 [28]. The primary outcome identied was ICU mortality, and the secondary outcomes were VAP, acute respiratory distress syndrome (ARDS), barotrauma, the occurrence of atelectasis, and the development of hypoxemia. The application of prophylactic PEEP in non-hypoxemic ventilated patients was found to reduce the number of episodes of hypoxemia and the incidence of VAP [28]. Placing the patient undergoing mechanical ventilation in the prone position appears to be associated with a reduction in aspiration of gastric contents and a reduction in VAP incidence. However, there is currently a lack of data from large-scale clinical studies to validate the effectiveness and feasibility of this strategy. For example, a multicenter prospective study conducted on ICU patients undergoing mechanical ventilation showed that the prone position is not easily achieved, and therefore its effectiveness is probably negative [29]; these data were also conrmed in children [30]. The effectiveness of the positioning of mechanically ventilated patients in the prevention of VAP has been the subject of a meta-analysis conducted on 15 studies and a total of 1169 patients. Even though the authors found a signicant decrease in the incidence of VAP (odds ratio (OR) 0.38, 95% CI; 0.280.53), they concluded that the data were too fragmentary to be conclusive [31]. More specic studies are required on this issue. The role of selective decontamination of the digestive tract is less controversial with regards to VAP. de La Cal et al. preformed a randomized double-blind study of 107 patients with severe burns at high risk of inhalation, to assess whether selective decontamination of the digestive tract was able to reduce the incidence of infections, morbidity, and mortality in critically ill patients. Statistical analysis demonstrated that the treatment was able to reduce mortality and VAP incidence compared with a control group [32].

reduced when a polyurethane tube was used, compared to a polyvinyl chloride one [18]. These results were corroborated by Lorente et al. in a randomized study of 280 patients. The VAP incidence was 22.1% in the patient group (n 140) with conventional polyvinyl chloride endotracheal tubes and no subglottic aspiration, compared to 7.9% (p 0.001) in the group of patients with polyurethane cuff tubes and subglottic continuous suction. These devices appear to reduce the incidence of VAP whether used early or late [19]. Automated devices more accurately assess the adherence of the endotracheal tube cuff; however, available data suggest that this is not sufcient to signicantly reduce the occurrence of VAP [20]. The use of endotracheal tubes coated with silver appears to contribute to the prevention of VAP. By analysis of data from bronchoalveolar lavage, The North American Silver Coated ENdo Tracheal study (NASCENT) of patients undergoing mechanical ventilation for more than 24 h showed that VAP onset was delayed and its incidence was reduced in the silver-coated tubes group compared to the control group [21]. Even the circuit components used for ventilation and humidication of the gas mixtures administered to patients can serve as a source of bacterial contamination, prompting the onset of pneumonia. However, the likelihood of this occurrence is in dispute. A study of an unselected population of 369 intensive care patients who underwent mechanical ventilation for more than 48 h demonstrated that VAP onset was not related to the device type used to humidify the gas mixture [22]. Similar results emerged from another study conducted on 181 patients [23]. In contrast, Lorente et al., in a small group of patients (106 patients) submitted to mechanical ventilation for more than 5 days, demonstrated that VAP incidence is lower (15.69% vs 39.62%) with a heated humidier than a heat and moisture exchanger [24]. Therefore, it is possible that the greater efcacy of humidication becomes apparent with more prolonged ventilation. Studies with larger series designed to test this possible effect would be useful. A recent meta-analysis (13 studies, 2580 patients) on this topic, but that did not highlight the temporal differences in ventilation, failed to demonstrate any difference in the incidence of VAP with passive or active humidiers [25]. The tracheostomy is a procedure commonly performed in patients undergoing mechanical ventilation over shorter and longer periods. An early tracheostomy may reduce the duration of mechanical ventilation and the incidence of respiratory tract infections, as well as improve patient comfort and reduce respiratory dead space.

Infection prevention in the intensive care unit Selective decontamination of the digestive tract was also found to result in an effective reduction of lower airway infections (30.9% vs 50% in the control group) in 401 multiple trauma patients submitted to ventilation [33]. A recent meta-analysis on 5939 patients stated that the 28-day mortality can be reduced by an estimated 3.5 percentage points with the use of selective decontamination of the digestive tract [4]. Finally, a signicant reduction in the incidence of VAP can be achieved with the use of non-invasive methods of ventilation. In a meta-analysis of 12 trials and 530 patients, non-invasive weaning was signicantly associated with a reduced VAP incidence (RR 0.29, 95% CI; 0.190.45) [34]. Catheter-related bloodstream infections (CRBSI) Given the incidence and clinical impact of catheterrelated infections (5.3 CRSBI per 1000 catheterdays), practical guidelines for their prevention were proposed in 2002, based on type-A evidence [35]. The education of medical staff regarding careful surveillance of control measures to prevent infection is encouraged. It is important to maintain aseptic techniques during the insertion of intravenous catheters and when applying dressings. Skin disinfection must be done with an appropriate antiseptic before insertion of the catheter and during dressing changes. Topical antibiotics should not be used on the insertion site. To attain the lowest risk of complications for the therapy type and expected duration of therapy, the type of catheter, insertion technique, and insertion site should be chosen carefully. Any catheter that is no longer essential should be removed promptly. Catheters impregnated with an antimicrobial or antiseptic are the best choice if they are to remain in place for more than 5 days, and if the infection rate in the ward remains high following the implementation of a global strategy. The risks and benets of placing a central venous catheter (CVC) in the recommended site must be ascertained: subclavian access is recommended for reducing infection in non-tunnelled catheters, and jugular vein or femoral vein use is recommended for dialysis catheter. Routine exchange by guide-wire should not be used to prevent infections. Clinical trials have recently been used to assess various methods for preventing CRBSI. For example, the use of particular types of medicated catheters appears to be correlated with a reduced incidence of catheter-related infections. A randomized study of 646 catheterizations compared the effectiveness of silverplatinumcarbon antimicrobial catheters with

247

rifampicinminocycline-medicated catheters. Catheters with silverplatinumcarbon served as effective antimicrobials, but the proportions of catheter-related infections were extremely low in both groups (1.4% for silverplatinumcarbon catheters vs 1.7% for medical catheters with rifampicinminocycline) [36]. Rupp et al. initiated a multicenter randomized double-blind controlled study of 780 patients to compare the incidence of infections due to the use of catheters medicated with chlorhexidine and sulfadiazine versus standard catheters. The results suggested that medical catheters are highly tolerated by the patient, with less colonization by pathogenic organisms at the time of removal. The main colonizing microorganisms were found to be coagulase-negative staphylococci and other Gram-positive microorganisms. Non-infectious adverse events occurred in both groups with comparable frequencies [37]. However, a recent prospective multicenter randomized controlled study demonstrated that there was no effective reduction in infection if multi-lumen CVCs or catheters impregnated with silver were used. In both groups of patients the incidence of infections was high: 2.5% in the standard catheter group vs 2.7% in the multi-lumen silver-impregnated catheter group [38]. Tunnelled catheters are often used in order to prevent colonization and subsequent infections related to long-term catheter use. Darouiche et al. showed that a group of patients with long-term antimicrobial-medicated catheters experienced a lower incidence of catheter-related infections than patients with tunnelled catheters (3.6 vs 1.43 per 1000 catheter-days) [39]. The impact of the site of catheter insertion on the prevention of catheter-related infections has not yet been determined. In a recent multicenter randomized investigation, Parienti et al. studied the incidence of infection in patients with CVCs, comparing femoral vs jugular access. The entire cohort of patients was subjected to cycles of short-term dialysis. The risk of colonization (assessed per 1000 catheter-days) was found to be similar in both groups: 40.8 for femoral access vs 35.7 for jugular access. However, a higher infection incidence occurred in patients with a body mass index 28.4 with femoral central venous access (50.9 femoral vs. 24.5 jugular). The risk of haematoma was highest when using jugular access [40]. Careful disinfection of the CVC insertion site may reduce the incidence of infection. Mimoz et al. conducted a randomized study of 538 CVCs with jugular and subclavian access, demonstrating that the use of chlorhexidine may represent a valid alternative to the use of povidoneiodine alcohol. Chlorhexidine was able to reduce the incidence of colonization by

248

A. D. Filippo et al. double-blind controlled study of 212 patients enrolled consecutively after traumatic events, compared the UTI incidence in patients with silicone urinary catheters with that in patients who were provided with catheters impregnated with nitrofurazone. There was signicantly less bacteriuria and funguria associated with the use of nitrofurazone-impregnated catheters than with the silicone urinary catheters (9.1% vs 24.7%). The clinical signicance of asymptomatic bacteria and fungi in urine was unclear, limiting the study [48]. However, the use of hydrophilic catheters in a randomized controlled trial of self-intermittent catheterization of patients after spinal injury did not signicantly reduce the UTI incidence compared to standard catheters [49]. Finally, the efcacy of prophylactic antibiotic therapy before removal of the bladder catheter was assessed. This prospective randomized study was conducted on 239 patients undergoing major abdominal surgery who were catheterized perioperatively; the usefulness and effectiveness of administration of trimethoprimsulfamethoxazole in 3 doses was evaluated. Urine cultures were taken before and 3 days after removal of the bladder catheter. The administration of trimethoprimsulfamethoxazole signicantly reduced the incidence of symptomatic urinary infection if administered before removal of the bladder catheter (4.9% in the analysis group vs 21.6% in the control group; p 0.001) [50].

50% (p 0.002) for the same incidence of overt bacterial infection (p 0.09) [41]. Bleasdale et al. conrmed these data in a randomized study, emphasizing that the use of chlorhexidine for daily patient hygiene can reduce the incidence of primary systemic infections [42]. Timsit et al. evaluated the effectiveness of using chlorhexidine gluconate-impregnated sponges to reduce the incidence of infection originating from the site of catheter insertion. The randomized controlled trial conducted in 3778 catheters kept in place for an average of 6 days demonstrated that the use of chlorhexidine-medicated wipes reduced the incidence of infection [43]. In a recent prospective randomized controlled trial on 601 patients with 9731 catheter-days, Ruschulte et al. demonstrated that the use of chlorhexidine gluconate-impregnated wound dressings reduced the incidence of CRBSI in comparison to standard dressings (RR 0.54, CL 0,310.94) [44]. In another recent prospective before-and-after study of 1271 patients in a surgical ICU, a simple daily reminder to physicians concerning the continued utility of the CVC and the subsequent prompt removal of the CVC if no longer required, resulted in a reduction in the incidence of CRBSI from 1.8% to 0.3% [45]. Finally, worth a special mention, a meta-analysis by Silvestri et al. showed that decontamination of the digestive tract is effective in reducing the emergence of overall bloodstream infections (OR 0.73, 95% CI; 0.590.9) and Gram-negative blood stream infections (OR 0.39, 95% CI; 0.24 0,63) and mortality [46]. Urinary tract infections (UTIs) Several studies have provided useful information regarding the prevention of UTIs [47]. Closed drainage systems are recommended after aseptic placement of the urinary catheter; catheters should only be inserted for the appropriate indications and should be kept in place only as long as necessary. The duration and use of bladder catheterization should be minimized in patients at increased risk for UTI, such as women, the elderly, and patients with compromised immune systems. Aseptic insertion of the catheter should be ensured. If the rate of UTIs is not reduced after the implementation of a comprehensive strategy (appropriate positioning and proper aseptic maintenance), the use of catheters impregnated with an antimicrobial or antiseptic should be considered. The implementation of hand hygiene measures before insertion of a catheter or any manipulation of the catheter site or devices is mandatory. Several recent clinical trials have been performed regarding the prevention of UTI. A randomized

Conclusions Recent ndings appear to conrm the effectiveness of certain procedures for the prevention of infections, particularly with regard to VAP. Decontamination of the oral cavity, the continuous suction of subglottic secretions, selective decontamination of the digestive tract, and, for high-risk patients, endotracheal tubes with silver, have all been shown to be useful in the prevention of VAP. Medicated catheters and chlorhexidine-based dressings have been shown to be efcacious against CRBSI. The use of medical catheters has been shown to prevent UTIs. All these procedures can be incorporated into departmental protocols for the prevention of nosocomial infections in ICUs. Further studies are required on the efcacy of other methods in the prevention of ICU infections for which there is currently insufcient evidence, such as patient positioning, the method of humidication, and early tracheostomy. Declaration of interest: The authors did not receive any grants or funding for the research. The authors declare that they have no conict of interest.

Infection prevention in the intensive care unit References

[1] Centers for Disease Control and Prevention. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53(RR-3):136. [2] Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of ventilatorassociated pneumonia in ICU populations. Intensive Care Med 2006;32:2306. [3] Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007;334: 889. [4] de Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf T, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009;360:2031. [5] Panchabhai TS, Dangayach NS, Krishnan A, Kothari VM, Karnad DR. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest 2009;135: 11506. [6] Koeman M, van der Ven AJ, Hak E, Joore HC, Kaasjager K, de Smet AG, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006;173:134855. [7] Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol 2008;29:1316. [8] Fourrier F, Dubois D, Pronnier P, Herbecq P, Leroy O, Desmettre T, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med 2005;33:172835. [9] Seguin P, Tanguy M, Laviolle B, Tirel O, Malldant Y. Effect of oropharyngeal decontamination by povidoneiodine on ventilator-associated pneumonia in patients with head trauma. Crit Care Med 2006;34:15149. [10] Pobo A, Lisboa T, Rodriguez A, Sole R, Magret M, Treer S, et al.; RASPALL Study Investigators. A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest 2009;136:4339. [11] Caruso P, Denari S, Ruiz SA, Demarzo SE, Deheinzelin D. Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit Care Med 2009;37:328. [12] Lorente L, Lecuona M, Martn MM, Garca C, Mora ML, Sierra A. Ventilator-associated pneumonia using a closed versus an open tracheal suction system. Crit Care Med 2005;33:1159. [13] Lorente L, Lecuona M, Jimnez A, Mora ML, Sierra A. Tracheal suction by closed system without daily change versus open system. Intensive Care Med 2006;32:53844. [14] Jongerden IP, Rovers MM, Grypdonck MH, Bonten MJ. Open and closed endotracheal suction systems in mechanically ventilated intensive care patients: a meta-analysis. Crit Care Med 2007;35:26070. [15] Bouza E, Prez MJ, Muoz P, Rincn C, Barrio JM, Hortal J. Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest 2008;134: 93846.

249

[16] Lacherade JC, De Jonghe B, Guezennec P, Debbat K, Hayon J, Monsel A, et al. Intermittent subglottic secretion drainage and VAP. Am J Respir Crit Care Med 2010;182:9107. [17] Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med 2005;118:118. [18] Poelaert J, Depuydt P, De Wolf A, Van de Velde S, Herck I, Blot S. Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: a pilot study. J Thorac Cardiovasc Surg 2008;135:7716. [19] Lorente L, Lecuona M, Jimnez A, Mora ML, Sierra A. Inuence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am J Respir Crit Care Med 2007;176:107983. [20] Valencia M, Ferrer M, Farre R, Navajas D, Badia JR, Nicolas JM, et al. Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trial. Crit Care Med 2007;35:15439. [21] Kollef MH, Afessa B, Anzueto A, Veremakis C, Kerr KM, Margolis BD, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA 2008;300:80513. [22] Lacherade JC, Auburtin M, Cerf C, Van de Louw A, Sour L, Rebufat Y, et al. Impact of humidication systems on ventilator-associated pneumonia: a randomized multicenter trial. Am J Respir Crit Care Med 2005;172:127682. [23] Boots RJ, George N, Faoagali JL, Druery J, Dean K, Heller RF. Double-heater-wire circuits and heat-and-moisture exchangers and the risk of ventilator-associated pneumonia. Crit Care Med 2006;34:68793. [24] Lorente L, Lecuona M, Jimnez A, Mora ML, Sierra A. Ventilator-associated pneumonia using a heated humidier or a heat and moisture exchanger: randomized controlled trial [ISRCTN88724583]. Crit Care 2006;10:R116. [25] Siempos II, Vardakas KZ, Kopterides P, Falagas ME. Impact of passive humidication on clinical outcomes of mechanically ventilated patients: a meta-analysis of randomized controlled trials. Crit Care Med 2007;35:284351. [26] Blot F, Similowski T, Trouillet JL, Chardon P, Korach JM, Costa MA, et al. Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients. Intensive Care Med 2008;34:177987. [27] Barquist ES, Amortegui J, Hallal A, Giannotti G, Whinney R, Alzamel H, et al. Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. J Trauma 2006;60:917. [28] Manzano F, Fernndez-Mondjar E, Colmenero M, Poyatos ME, Rivera R, Machado J, et al. Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients. Crit Care Med 2008;36: 222531. [29] van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, Joore HC, van Schijndel RJ, van der Tweel I, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006;34:396402. [30] Aly H, Badawy M, El-Kholy A, Nabil R, Mohamed A. Randomized, controlled trial on tracheal colonization of ventilated infants: can gravity prevent ventilator-associated pneumonia? Pediatrics 2008;122:7704. [31] Delaney A, Gray H, Laupland KB, Zuege DJ. Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care 2006;10:R70. [32] de La Cal MA, Cerd E, Garca-Hierro P, van Saene HK, Gmez-Santos D, Negro E, et al. Survival benet in critically

250

A. D. Filippo et al.
ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, doubleblind trial. Ann Surg 2005;241:42430. Stoutenbeek CP, van Saene HK, Little RA, Whitehead A; Working Group on Selective Decontamination of the Digestive Tract. The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial. Intensive Care Med 2007;33:26170. Burns KE, Adhikari NK, Keenan SP, Meade M. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ 2009; 338:b1574. OGrady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51 (RR-10):129. Fraenkel D, Rickard C, Thomas P, Faoagali J, George N, Ware R. A prospective, randomized trial of rifampicinminocycline-coated and silverplatinumcarbon-impregnated central venous catheters. Crit Care Med 2006;34:66875. Rupp ME, Lisco SJ, Lipsett PA, Perl TM, Keating K, Civetta JM, et al. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: a randomized, controlled trial. Ann Intern Med 2005;143:57080. Kalfon P, de Vaumas C, Samba D, Boulet E, Lefrant JY, Eyraud D, et al. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Crit Care Med 2007;35:10329. Darouiche RO, Berger DH, Khardori N, Robertson CS, Wall MJ Jr, Metzler MH, et al. Comparison of antimicrobial impregnation with tunneling of long-term central venous catheters: a randomized controlled trial. Ann Surg 2005;242: 193200. Parienti JJ, Thirion M, Mgarbane B, Souweine B, Ouchikhe A, Polito A, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA 2008;299:241322. Mimoz O, Villeminey S, Ragot S, Dahyot-Fizelier C, Laksiri L, Petitpas F, et al. Chlorhexidine-based antiseptic solution vs alcohol-based povidoneiodine for central venous catheter care. Arch Intern Med 2007;167:206672. Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007;167: 20739. Timsit JF, Schwebel C, Bouadma L, Geffroy A, GarrousteOrgeas M, Pease S. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheterrelated infections in critically ill adults: a randomized controlled trial. JAMA 2009;301:123141. Ruschulte H, Franke M, Gastmeier P, Zenz S, Mahr KH, Buchholz S, et al. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Ann Hematol 2009;88:26772. Seguin P, Laviolle B, Isslame S, Coue A, Maleedant Y. Effectiveness of simple daily sensitization of physician to the duration of central venous and urinary tract catheterization. Intensive Care Med 2010;36:12026. Silvestri L, van Saene HK, Milanese M, Gregori D, Gullo A. Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients. Systematic review of randomized, controlled trials. J Hosp Infect 2007;65:187203. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31:31926. Stensballe J, Tvede M, Looms D, Lippert FK, Dahl B, Tnnesen E, et al. Infection risk with nitrofurazone-impregnated urinary catheters in trauma patients: a randomized trial. Ann Intern Med 2007;147:28593. Cardenas DD, Hoffman JM. Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: a randomized controlled trial. Arch Phys Med Rehabil 2009;90:166871. Pfefferkorn U, Lea S, Moldenhauer J, Peterli R, von Fle M, Ackermann C. Antibiotic prophylaxis at urinary catheter removal prevents urinary tract infections: a prospective randomized trial. Ann Surg 2009;249:5735.

[42]

[33]

[43]

[34]

[44]

[35]

[45]

[36]

[46]

[37]

[47]

[38]

[39]

[48]

[49]

[40]

[50]

[41]

Copyright of Scandinavian Journal of Infectious Diseases is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.