May,2020
Running head: PROBIOTIC AND VENTILATOR ASSOCIATED PNEUMONIA 1
1
Probiotic Use in Prevention of Ventilator Associated Pneumonia
The Ventilator associated pneumonia complicate care of patient receiving mechanical ventilation. It is defined as pneumonia that develops 48 hours or more after a patient is mechanically ventilated (Medspace,2015). This condition is a significant cause of morbidity and mortality in ventilated patient. Ventilator- associated pneumonia is responsible for between 24- 47 % of ICU acquired infections (Grap, 2012). As per CDC (2018) in 2011 were reported 157,500 cases of Ventilator-associated Pneumonia (VAP) in the United States of America (CDC, 2018). The estimated cost of Ventilator-Associate Pneumonia is calculated between $40,000 and $80,000 per patient/ hospital admission, with an $1.2 billion per annual cost (Marya, 2010). In the prevention of ventilator associated pneumonia, some actions are applied to prevent the occurrence of this respiratory complication in critically ill and intubated patients. As a novelty to these preventive measures in recent years, several studies have been conducted to demonstrate the beneficial effect of probiotics in the prevention of ventilator-associated pneumonia. As per some of these studies, the Probiotic use can decrease the incidence of this respiratory complication. The role of probiotic in decreasing the risk of infections in Intensive Care Unit (ICU) was described for the first time by Petrof in 2012 (Petrof et al., 2012). The purpose of this literature review will be to determine if the probiotic use in prevention of ventilator associated pneumonia is more effective than the conventional method. The method used in this research will be the review of relevant articles related to the use of probiotics in the prevention of Ventilator- Associated Pneumonia (VAP).
Significance of the Practice Problem
The risk of nosocomial diseases specifically in critically ill patients in ICU is considerable. This nosocomial infection without doubt increases morbidity and mortality as well as the cost of health care. VAP is one of these nosocomial diseases. In general, pneumonia is the second cause most common nosocomial infection. Oropharyngeal colonization by the endogenous flora or through the contamination of staff’s hands, instrumentation, medical equipment, water or air in the intensive care environment is considered the main way of acquiring VAP. The agents identified most commonly as responsible of Ventilator-associated Pneumonia has been: methicillin- resistant Staphylococcus aureus (MRSA) (40%), Escherichia coli (50%), Klebsiella pneumonia (30%), Enterobacter cloacae (10%) and Citrobacter freundii (10%), Pseudomonas aeruginosa 20% and Acinetobacter baumannii 18%. (Ahmad, Bacha, Bakht, Ahmed, 2017). This diagnosis affects 24-47 % of all critically ill patients (Grap, 2012). While in the VAP of late onset (VAP that appears 5 or more days after mechanical ventilation started) the most frequent microorganisms responsible for this complication have been: Pseudomonas aeruginosa, Acinetobacter, Enterobacter spp. and methicillin-resistant S. aureus (Karacaer, Hamed, Özogul, Glew, & Özcengiz, 2017). As mention previously, the Ventilator-associated Pneumonia has an estimated annual cost of $1.2 billion (Marya, 2010). Daily bedside patient’s evaluation in conjunction with chest radiography can only be suggestive of the presence or absence of VAP. Certainly, the repercussions of the appearance of a VAP in a critically ill patient are a concern in the health system. VAP prevention measures usually use prophylactic antibiotics that lead to increased antimicrobial resistance. A set of conventional measures are carried out with the aim of preventing VAP. Additionally, in the United States, VAP has been proposed as an indicator of quality of care in public reporting, and its prevention is a national patient safety goal.
Research Question
Is the probiotic’s use in prevention of ventilator associated pneumonia more effective than the conventional method?
Objectives:
1.To determine if the probiotic use in prevention of ventilator associated pneumonia is more effective than the conventional method.
2. To compare use of probiotic and conventional method in prevention of ventilator associated pneumonia.
3. To estimate cost-benefit of using probiotic ventilator associated pneumonia prevention.
Theoretical Framework
The Calixta Roy nursing theory will served as the foundation for this project. The Adaptation Model of Nursing was developed by Calixta Roy in 1976. For Callista Roy, human beings are not simply cause-effect, but she considered them holistic beings. At the same time, he considered that people were closely linked to the experiences they had experienced in the past, which makes each human being a unique, dignified and autonomous being and based on this concept, the nurse should base her relationship with the patient. The metaparadigm of the adaptation theory of Callista Roy include four components: person, health, environment and nursing. Environment is considered as all conditions, circumstances that include focal, contextual and residual stimuli. Person: people are described as a holistic and adaptable systems. These systems include people, groups like family, communities and society. Care, the goal of the nurse is to increase the ability of the patient and / or community groups to adapt, thus providing an improvement in the health of the individuals; and the last component is the health. For Callista Roy, health is the result of the individual's adaptation to their environment (Alligood, 2019). Critical care nursing carry for physical and emotional health of patient as well as their families. At the same time, the ICU nurses should be prepare for adapting the patient’s care quickly based on patient’s health progression or deterioration.
Synthesis of the Literature
According to Hellyer and collaborators (2016) this study evaluates conventional interventions called bundle of care, associated with VAP. These interventions are evidence-based practice commonly used in ICU setting. They assess some of them like: elevation of the head (30°–45°), daily sedation, and drainage of subglottic secretion. The pathogenesis of the VAP is highly related to the aspiration of content of the stomach and the oropharynx. Studies show a significant reduction in aspiration in patients lying down with an elevation of head between 30°–45°, thus a decrease in VAP. The Daily sedation interruption and assessment of readiness to extubate is another of the bundle of care. Two variants have been used: daily sedation interruption (DSI), and daily spontaneous breathing trial (SBT). The studies carried out have not shown a significant difference in the length of stay in ICU and the duration of the hospital stay or mortality. Use of drainage of subglottic secretion: this intervention was associated both with the VAP reduction and with the reduction of days in ICU with antibiotic treatment. Avoid programmed changes in the ventilator circuit. The frequent changes are linked to the appearance of VAP. This intervention not only reduced the incidence of VAP, but also has cost implications. According to Heller and other authors, 247 changes of ventilator circuits made every 7 days has a cost of $ 7,410.00, compared to routine changes at a cost of $ 330.00 (Hellyer, Ewan, Wilson, & Simpson, 2016).
As per Zubair and collaborators (2017), the clinical and economic characteristics of VAP are uncertain and with contradictory results. It is a challenge to estimate the true cost and clinical consequences associated with VAP. Countries like Pakistan carry out antimicrobial policies with a more rational approach with the aim of reducing mortality and morbidity rates, treatment time, hospitalization and reduction of resistant strains, as well as cost reduction. (Zubair, Ali, Zafar, Beg, Sial, 2017).
In this article made by Sadasivan and other author (2018) they carry out a review on the diagnosis of VAP and the strategies for its prevention. This diagnosis constitutes a severe complication of the critically ill patient and is associated with high mortality. Sadasivan and collaborators grouped the conventional strategies for the prevention of VAP in non-pharmacological and pharmacological. Among the non-pharmacological ones include: staff education in the Intensive Care Unit, hand hygiene, changes of patient’s head position, management of artificial airway, as well as management of mechanical ventilation. Within the pharmacological measures they mention: Measures to modify of oropharyngeal colonization, use of prophylaxis to decrease stress ulcer, ventilator sedation protocol, and scheduled switched on antibiotic class to reduce resistances. (Sadasivan, George, & Krishnakumar, 2018).
Branch and collaborators (2015) describe the VAP as a nosocomial infection with a high cost and negative repercussions for the patient. Many strategies have been described aimed at reducing the incidence of VAP. However, the relationship between the implementation of these strategies and the cost-benefit effect is still unknown (Branch, Wright & Howell 2015).
Tokmaij, Vermeuten, Müller, Kwakman, Schultz, and Zaat (2015) state in their research that VAP is one of more common nosocomial infection in intubated patients. The use of endotracheal tubes increases the risk of developing ventilator associated pneumonia. Silver-coated Endotracheal tubes (ETTs) slowly release silver cations, which appear to have an antimicrobial effect. This antimicrobial effect of the silver coating of the ETTs could be an effective intervention in the prevention of VAP. (Tokmail, Vermeulen, Müller, Kwakman, Schultz & Zaat, 2015).
As per Cook, Johnston, Marshall, Lauzier, Thabane, and Mehta (2016) the ingestion of probiotics offers health benefits. Randomized studies have shown that probiotics can decrease the occurrence of VAP and other infections in critically ill patients. Because previous studies have been small studies, largely single center, and at risk of bias, this research had as objective to demonstrate the feasibility of a larger trial on the effect of probiotics in the prevention of Ventilator-associated Pneumonia (Cook, Johnstone, Marshall, Lauzier, Thabane, Mehta ... & Taylor 2016).
Weng, Guo-Li, Mao, Wang, and Zeng (2017) describe that in those patients who require mechanical ventilation for more than 72 hours, the pneumonia associated with the ventilator remains one of the first causes of morbidity and mortality. Until now, the use of probiotics in the prevention of VAP is controversial. This study was designed to exhaustively evaluate the effect of probiotics in the prevention of VAP (Weng, Li, Mao, Feng, Wang, … Zeng, 2017).
Zeng and collaborators (2016) in their research estimate the probable protective effect of probiotics on ventilator-associated pneumonia (VAP). They observe 235 critically ill adult patients on mechanical ventilation for ≥48 h. Randomly they received a probiotic capsule of 0.5 g three times daily through a nasogastric feeding tube plus typical preventive approach for 14 days. Consequently, the mean time to develop VAP was meaningfully longer in the probiotics group than in the control group (Zeng, Wang, Zhang, Qi, Wang, Ma, … Qu, 2016).
In this article Marini, and Mundekkadan (2016), emphasize the importance of reducing the Ventilator-associated Pneumonia and describe multiple practical recommendations to address them. They evaluated the compliance with all conventional method to prevent VAP like: head of bed elevation (HOB), daily sedation vacations, daily assessment of readiness for extubation, oral care protocol, cuff pressure monitoring, subglottic suctioning. As per Marini and Mundekkadan, as documented in previous literature, the implementation of these actions allowed to decrease the incidence of VAP in critical patients (Marini, Khan, & Mundekkadan, 2016).
Manzanares and other authors (2016) evaluate the effectiveness of probiotics and symbiotic in critical illnesses and some complications such as VAP. To achieve this purpose, the authors reviewed evidence between the years 1980 and 2016, analyzing the results in those patients who were treated with probiotics or in combination with symbiotic. Manzanares y collaborators concluded that the use of probiotics was associated with a significant decrease in infections, as well as a reduction in the incidence of VAP was found (Manzanares, Lemieux, Langlois, & Wischmeyer,2016).
Mahmoodpoor, Hamishehkar and other authors (2019) conducted a prospective Double-Blind Randomized Controlled Trial where Probiotic preparation was administered to 100 critically ill patients in mechanic ventilation support for more than 48 hours. As a result, they got a decrease in length of ICU and hospital stay. However, this study could not demonstrate that the administration of probiotics has a significant effect on the incidence and mortality of VAP in patients with mechanical ventilation (Mahmoodpoor, Hamishehkar, Asghari, Abri, Shadvar & Sanaie, 2019).
According to Wischmeyer and collaborators (2016) this study is based on the belief of the relationship that exists between the loss of balance between the health promoter microbes and the overgrowth of pathogenic bacteria. This phenomenon is called dysbiosis. According to this concept, this disbalance contributes to the occurrence of nosocomial diseases such as Ventilator- associated Pneumonia, in addition to sepsis which can lead to multiorgan failure. Wischmeyer and collaborators determined that based on the results obtained by them, the use of probiotics could restore a healthy microbiome. This would reduce the incidence of complications associated with the appearance of nosocomial diseases in critically ill patients (Wischmeyer, McDonald, & Knight, 2016).
Karacaer, Hamed, Özogul, Glew, & Özcengiz (2017) conducted a comprehensive review of the studies that demonstrated the effect of the use of probiotics in the prevention of Ventilator-associated pneumonia. In their research, they reviewed the safety of probiotics, as well as their therapeutic properties and the most commonly used strains. In addition, they analyzed the mechanism of action of probiotics and the influence of bacteriocin on the growth of human pathogens. Side effects and limitations of the use of probiotics were also reviewed by Karacaer and collaborators (Karacaer, Hamed, Özogul, Glew, & Özcengiz, 2017).
Kothari and other authors (2019) analyzed the use of probiotics, their benefits and adverse effects. In this research they describe certain complications associated with the use of probiotics such as sepsis, infective endocarditis, localized and systemic opportunistic infections: bacteremia or fungemia, and ischemic bowel. In infant (< 1 year old) the use of probiotics has been linked to a higher risk of asthma and allergic rhinitis. The mechanism responsible for these adverse effects is bacterial translocation as they describe in this review (Kothari, Patel, & Kim, 2019).
The article made by Fawzy, Genena, & Sewify (2017) mention how the deterioration of the intestinal barrier is associated with systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS). They confirm that probiotics are generally well tolerated, and their adverse effects are rare. Understanding their mechanism of action would help to better define their valuable effects. According to this research, these living microorganisms provide benefits in VAP, in diarrhea associated with antibiotics, and in necrotizing colitis. They identify the heterogeneity of the probiotic strains, the duration of administration and the small sizes of the samples in previous studies as the factors responsible for the limited usefulness of the probiotics in these nosocomial diseases (Fawzy, Genena, & Sewify, 2017).
Practice Recommendations
According to the literature reviewed until now, the evidence shows that undoubtedly the use of probiotic is a tool under evaluation. The use of probiotics could be helpful in the prevention of nosocomial infections such as VAP. However, there are not enough conclusive studies on the efficacy and safety of the use of probiotics. It is advisable to continue using conventional methods of prevention of VAP that have proven their effectiveness. Those studies that have shown an association between the use of live microorganisms and the decrease in the incidence of VAP are of low quality. At this time with the literature reviewed I can say that the role of probiotics in the prevention of nosocomial diseases in the ICU environment such as VAP is contradictory. At the same time, it is advisable to develop future studies with considerable samples that help to corroborate or to refute the benefits of probiotics.
Project Description
This project will be completed through a literature review. This will be carried out through Google Scholar, CINHAL, Ana G. Mendez Virtual Libraries, WorldCat, PubMed, Internet database. The research will be peer reviewed. A minimum 30 articles of no more than 5 years will be reviewed. I will use some keywords for my search like: Probiotic, Ventilator-Associated Pneumonia, ICU, conventional methods.
The results obtained from the study will contribute to determine if the probiotic use in prevention of ventilator associated pneumonia is more effective than the conventional method, with a more cost-effective result.
All information collected in this review will be kept in a locked dresser in the principal investigator's office for a period of 5 years. Both, the principal investigator and the mentor will have access to this material. After this time (5 years), the data will be eliminated with a paper shredder and discarded.
Project Evaluation Results
Once the study data is collected, these will be analyzed and included in the final report. The coding and editing of the data will be carried out. The objective of data analysis is to eradicate errors that may have occurred during the data collection. My research question, that is if the probiotic’s use in prevention of ventilator associated pneumonia is more effective than the conventional method could be answered at the end of this study.
Summarize tables with all citation will be presented in appendix A&B; appendix A will be used for the summary of primary research evidence, and appendix B will be used for the summary of the systematic reviews.
Appendix A will include the citation, question or hypothesis, and theoretical foundation, research designated and sample size, key findings, recommendations or implications, and level of evidence, of each article. Appendix B will include citations, question, search strategy, inclusion/exclusion criteria, data, extraction and analysis, key finding, recommendation / implications and level of evidence of each article.
Each article will be evaluated as relevant or not to answer my research question. An excel database will be used to computes all information, and SPSS statistics package will be used to summarize some results.
Discussion and Implications for Nursing and Healthcare
The pneumonia associated with the ventilator is a pneumonia that can appear in those patients who are critically ill and are mechanically ventilated for more than 48 hours. This complication has a high mortality rate despite the use of preventive measures, becoming the second most common nosocomial infection in the United States. In the same way, it is associated with a high cost of medical attention. According to some studies, the use of probiotics in recent years suggest a way to prevent this infection by strengthening the function of the intestinal barrier.
Some of the studies reviewed concluded the positive effect of the use of probiotics in reducing the incidence of VAP in critically ill patients. At the same time some of these investigations demonstrated a reduction in mortality, duration of mechanical ventilation and in the length of stay in ICU. These same aspects analyzed in other studies the results are not conclusive. Based on the literature reviewed, until now, the quality of the evidence is low, and results are contradictory basically due to non-representative samples and errors in the selection of the methodology. Because of these facts, it is convenient to continue the research to answer my research question.
Plans for Dissemination
To achieve the purpose of making our research known, different types of media will be used. In the same way interpersonal communication will be of vital importance to disseminate this project. Also, other forms of dissemination will be used as: a power point and poster will be presented at the Ana G Mendez University. The power point will have a duration of no more than 30 minutes and will be presented to the teacher and classmates. While the poster, which will include a summary of this research, will be shown in the Ana G Mendez University room of the South Florida campus. In the library of this university we will leave a copy of this literature review to be used by those who are interested in the subject.
Summary and Conclusion
Currently, the indiscriminate use of antibiotics has led to high antimicrobial resistance and to dysbiosis in ICU settings. These conditions are directly proportional to the increase in nosocomial infections including VAP, sepsis and multiorgan failures that lead to an increase in mortality rates. The use of probiotics is a hopeful solution as preventive therapy for these complications. If its efficacy were proven, it would help to restore the microbiome, improving the results in critically ill patients.
In view of the literature reviewed so far, I cannot confirm that the benefits of probiotics are superior to the benefits conferred by conventional methods for the prevention of VAP. For this reason, it is convenient to continue reviewing literature on this subject to check and verify my research question and objectives of this review.
References
Ahmad, S., Bacha, N., Bakht, J., & Ahmed, J. (2017). Characterization of pathogens involved in ventilator associated pneumonia in surgical and medical intensive care units-A single center experience. Pakistan journal of pharmaceutical sciences, 30(6).
Alligood, M. R., & Tomey, A. M. (2011). Modelos y teorías en enfermería. Elsevier España.
Branch-Elliman, W., Wright, S. B., & Howell, M. D. (2015). Determining the Ideal Strategy for Ventilator-associated Pneumonia Prevention. Cost–Benefit Analysis. American Journal of Respiratory and Critical Care Medicine, 192(1), 57-63. doi:10.1164/rccm.201412-2316oc
Center for Disease Control and Prevention. (2018). HAI Data. Retrieved from http://www.cdc.gov/hai/surveillance/index.html
Fawzy, M., Genena, D., & Sewify, K. (2017). Should probiotics be routinely used in critically ill patients.
Grap, M. J., Munro, C. L., Unoki, T., Hamilton, V. A., & Ward, K. R. (2012). Ventilator-associated Pneumonia: The Potential Critical Role of Emergency Medicine in Prevention. The Journal of Emergency Medicine, 42(3), 353-362. doi:10.1016/j.jemermed.2010.05.042
Hellyer, T. P., Ewan, V., Wilson, P., & Simpson, A. J. (2016). The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. Journal of the Intensive Care Society, 17(3), 238-243. doi:10.1177/1751143716644461
Johnstone, J., Meade, M., Marshall, J., Heyland, D. K., Surette, M. G., & Cook, D. J. (2015). Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial—PROSPECT: protocol for a feasibility randomized pilot trial. Pilot and Feasibility Studies, 1(1). doi:10.1186/s40814-015-0013-3
Karacaer, F., Hamed, I., Özogul, F., Glew, R. H., & Özcengiz, D. (2017). The function of probiotics on the treatment of ventilator-associated pneumonia (VAP): facts and gaps. Journal of Medical Microbiology, 66(9), 1275-1285. doi:10.1099/jmm.0.000579
Kothari, D., Patel, S., & Kim, S. (2019). Probiotic supplements might not be universally-effective and safe: A review. Biomedicine & Pharmacotherapy, 111, 537-547. doi:10.1016/j.biopha.2018.12.104
Mahmoodpoor, A., Hamishehkar, H., Asghari, R., Abri, R., Shadvar, K., & Sanaie, S. (2019).
Effect of a Probiotic Preparation on Ventilator‐Associated Pneumonia in Critically Ill
Patients Admitted to the Intensive Care Unit: A Prospective Double‐Blind Randomized Controlled Trial. Nutrition in Clinical Practice, 34(1), 156-162.
Manzanares, W., & Wischmeyer, P. E. (2017). Erratum to: Probiotic and synbiotic therapy in critical illness: a systematic review and meta-analysis. Critical Care, 21(1). doi:10.1186/s13054-017-1622-4
Marini, A. L., Khan, R., & Mundekkadan, S. (2016). Multifaceted bundle interventions shown effective in reducing VAP rates in our multidisciplinary ICUs. BMJ Quality Improvement Reports, 5(1), u205566.w2278. doi:10.1136/bmjquality.u205566.w2278
Petrof, E. O., Dhaliwal, R., Manzanares, W., Johnstone, J., Cook, D., & Heyland, D. K. (2012). Probiotics in the critically ill. Critical Care Medicine, 40(12), 3290-3302. doi:10.1097/ccm.0b013e318260cc33
Richards, M. J., Edwards, J. R., Culver, D. H., & Gaynes, R. P. (1999). Nosocomial infections in medical intensive care units in the United States. Critical Care Medicine, 27(5), 887-892. doi:10.1097/00003246-199905000-00020
S, Z., H, A., F, Z., AE, B., AA, S., S, N., … A, T. (2017). Ventilator-Associated Pneumonia (VAP): Clinical Strategies, Treatment Challenges and Economic Concerns. Journal of Bioequivalence & Bioavailability, 09(04). doi:10.4172/jbb.1000338
Sadasivan, P., George, L., & Krishnakumar, K. (2018). Ventilator associated pneumonia- Diagnosis and Prevention strategies in critically ill patients:A.
Timsit, J., Esaied, W., Neuville, M., Bouadma, L., & Mourvillier, B. (2017). Update on ventilator-associated pneumonia.
Tokmaji, G., Vermeulen, H., Müller, M. C., Kwakman, P. H., Schultz, M. J., & Zaat, S. A. (2015). Silver-coated endotracheal tubes for prevention of ventilator-associated pneumonia in critically ill patients. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd009201.pub2
Ventilator-Associated Pneumonia: Overview of Nosocomial Pneumonias, Epidemiology of VAP, Clinical Presentation of VAP. (2017, January 6). Retrieved from https://emedicine.medscape.com/article/304836-overview
Virk, H. S., & Wiersinga, W. J. (2019). Current place of probiotics for VAP. Critical Care, 23(1). doi:10.1186/s13054-019-2325-9
Weng, H., Li, J., Mao, Z., Feng, Y., Wang, C., Ren, X., & Zeng, X. (2017). Probiotics for Preventing Ventilator-Associated Pneumonia in Mechanically Ventilated Patients: A Meta-Analysis with Trial Sequential Analysis. Frontiers in Pharmacology, 8. doi:10.3389/fphar.2017.00717
Wischmeyer, P. E., McDonald, D., & Knight, R. (2016). Role of the microbiome, probiotics, and ‘dysbiosis therapy’ in critical illness. Current Opinion in Critical Care, 22(4), 347-353. doi:10.1097/mcc.0000000000000321
Zeng, J., Wang, C., Zhang, F. S., Qi, F., Wang, S. F., Ma, S., & Qu, Y. (2016). Effect of probiotics on the incidence of ventilator-associated pneumonia in critically ill patients: a randomized controlled multicenter trial. Intensive care medicine, 42(6), 1018-1028.
Figure 1
PROBIOTIC AND VENTILATOR ASSOCIATED PNEUMONIA 14
Figures included here are most likely going to be figures illustrating your data analysis.
Appendix A
Summary of Primary Research Evidence
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