Ventilator-associated pneumonia (VAP) is defined as nosocomial pneumonia developing after 48 h or more of initiation of mechanical ventilation. It is the most common hospital-associated infection (HAI) in critically ill adult patients, and is the 2^nd most common after bloodstream infection for the pediatric age group population. VAP accounts for about 20% of all HAI among patients in pediatric intensive care unit (PICU) and has a rate of (2.9-21.6)/1,000 ventilator days [1,2,3,4]

Furthermore, some data suggested higher mortality rate for mechanically ventilated pediatric patients with VAP compared with those without VAP. Hospital costs and the length of ICU stay were significantly increased for pediatric patients with VAP compared with those without VAP [5,6].

There is no data available regarding mortality and morbidity from our institution on VAP in PICU and NICU. Therefore, we plan to know the prevalence of VAP in our PICU and NICU at IGMC Shimla.

Aim & Objectives 

• To find the mortality rate of VAP in children and infants requiring ventilatory support in NICU and PICU at IGMC Shimla (0-18y).

• To find the duration of stay of VAP in children and infants requiring ventilatory support in NICU and PICU at IGMC Shimla (0-18y).

Study Design 

Tertiary hospital based ,observational and prospective study.

Study Duration 

1 year (starting from 1^st july 2015 to 30 june 2016 )

Study Settings 

All patiens ( 0-18 years) admitted in PICU and NICU at I.G.M.C. and K.N.H. shimla on ventilator support for more than 48 hours.

Inclusion Criteria

All the patents admitted to PICU and NICU at IGMC Shimla and on ventilator support for more than 48 hrs.

Exclusion Criteria

• Severe acute malnutrition. 

• Chronic diseases (heart, kidney, lung).

• Congenital or acquired immunosuppression.

Method of Data Collection

All enrolled patients were subjected to detailed history and clinical examination 

Diagnostic criteria

Center of disease control and prevention defined (Centers for Disease Control and Prevention. [7]) criteria has been taken to diagnose VAP in our study. 

• Two or more abnormal chest radiographs with at least one of the following symptoms.

• Fever (>38°C) with no other recognized cause.

• Leukopenia (<4,000 white blood cells [WBC]/mm³) or leukocytosis (≥12,000 WBC/mm³)

Two of the Following Criteria

•  New onset of purulent sputum,

•  Change in character of sputum, 

• Increased respiratory secretions,

•  Increased suctioning requirements;

• Signs of respiratory distress such as: New onset of or worsening cough, dyspnea, or tachypnea; rales or bronchial breath sounds; and worsening gas exchange, increased oxygen requirements, or increased ventilation demand.

NNIS/CDC criteria do not require microbiologic confirmation to diagnose pneumonia.

This was a prospective observational study conducted for a period of one year (1^st July 2015 to June 2016), in the intensive care units (NICU and PICU) of department of Pediatrics, IGMC, Shimla. All patients admitted to PICU and NICU , who required ventilator support for more than 48 hours were included in the study. The patients on ventilator were examined twice daily by the resident in charge under the supervision of consultant for signs and symptoms suggestive of VAP; Fever / Hypothermia, increased respiratory efforts / ET secretions / requirement of oxygen and appearance of new chest signs. Routine investigations included X-ray chest, ABG, complete hemogram etc as per protocol. The cases were classified into suspected VAP or VAP cases as per inclusion and exclusion criteria.

During the one year study period, in all 1750 children (0-18 years) were admitted in NICU and PICU of children ward of IGMC, Shimla. Of these 85 required ventilatory support for more than 48 hours and constituted the study cohort.

Out of these 85 cases, 15 (17.6%) developed clinical features suspicious of VAP but only 10 of these fulfilled the diagnostic criteria and were labelled VAP. So incidence of VAP observed was 11.7 % 

Out of total 85 cases, hospital stay on ventilator was found to be more in VAP cases (11.6 days) as compared to non-VAP cases (5.3 days). Mortality was significantly high in VAP cases, 70% in VAP Cases and 37.35 in Non VAP cases. (p < 0.05) (Table 1).

Figure 1: Incidence of ventilator associated pneumonia

Table 1: Hospital stay and outcome of VAP patients

During the one year study period, in all 1750 children (0-18 years) were admitted in NICU and PICU of children ward of IGMC, Shimla. Of these 85 required ventilatory support for more than 48 hours and constituted the study cohort. Among these 15 were suspected to be suffering from VAP but only 10 cases fulfilled the diagnostic criteria and were diagnosed as VAP. So the incidence of VAP observed was 11.7%.

The published data in pediatric populations suggest that pediatric patients with VAP may have excess mortality and length of PICU and NICU stay. We observed average longer hospital stay (11.6 days) in VAP cases in comparison to non-VAP cases (5.3 days) which is similar to findings of E.Foglia et al.,[8] (27 days Vs 6 days), Rick Amato et al., [9] (16.3 days Vs 8.4 days), and Harsh Sharma et al., [10] (7.3 days Vs 4.78 days).

In the present series mortality among VAP cases was significantly high (70%) .Various studies done in past have found increased mortality among VAP cases in comparison to non VAP cases.Yasmine S. Galalet al., [11] observed 68.2%, mortality amongst VAP cases while it was 48.5% in non VAP cases. Our observation of mortality among VAP cases (70%) is closer to their observation. Rick Amato et al., [9] observed mortality (VAP19.1% non-VAP 7.2%). Harsh Sharma et al., [10] observed mortality more in non-VAP cases (VAP 12.5% Non-VAP 36.36%) which was lower than our observation.

The findings of the present study emphasize that the duration of hospital stay and mechanical ventilation of children (neonates, infants and children 1 to 18 yrs) admitted to NICUs and PICUs have a significant association with ventilator-associated pneumonia, which in turn, leads to an increase in the mortality rate. Prevention and timely treatment of this nosocomial infection are critical for improving the prognosis of these infants.

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2. Tablan, O.C. et al. “Guidelines for Preventing Health-Care–Associated Pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee.” MMWR Recommendations and Reports, vol. 53, 2004, pp. 1–36.

3. Elward, A.M. “Pediatric Ventilator-associated Pneumonia.” Pediatric Infectious Disease Journal, vol. 22, 2003, pp. 445–446.

4. Tang, C.W. et al. “Ventilator-associated Pneumonia after Pediatric Cardiac Surgery in Southern Taiwan.” Journal of Microbiology, Immunology, and Infection, vol. 42, no. 5, 2009, pp. 413–419.

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7. Centers for Disease Control and Prevention. Ventilator-Associated Pneumonia (VAP) Event. January 2012, pp. 1–13.

8. Foglia, E., M.D. Meier, and A. Elward. “Ventilator-associated Pneumonia in Neonatal and Pediatric Intensive Care Unit Patients.” Clinical Microbiology Reviews, vol. 20, no. 3, 2007, pp. 409–425.

9. Bigham, M.T. et al. “Ventilator-associated Pneumonia in the Pediatric Intensive Care Unit: Characterizing the Problem and Implementing a Sustainable Solution.” The Journal of Pediatrics, vol. 154, no. 4, 2009, pp. 582–587.

10. Sharma, H. et al. “A Study of Profile of Ventilator-associated Pneumonia in Children in Punjab.” Journal of Tropical Pediatrics, vol. 55, no. 6, 2009, pp. 393–395.

11. Galal, Y.S., M.R.L. Youssef, and S.K. Ibrahiem. “Ventilator-associated Pneumonia: Incidence, Risk Factors and Outcome in Paediatric Intensive Care Units at Cairo University Hospital.” Journal of Clinical and Diagnostic Research, vol. 10, no. 6, 2016, SC06.