**2.1 Symptoms and diagnosis of VAP**

The diagnosis of VAP in children can be made on a clinical basis without the use of bronchoscopy. A set of clinical diagnostic criteria and alternative criteria that vary with age are given in the table (**Table 1**). The presence of pneumatoceles on chest X-rays in children under 12 months of age meets the radiographic criteria for pneumonia, which are listed in the table. The diagnosis of VAP can be made based on clinical and radiographic criteria. Identification of the causative microorganism is essential for targeted antibiotic therapy. Identification of the microorganism is difficult because endotracheal tube culture is inaccurate due to colonization of the endotracheal tube and upper airways by gram-negative bacilli and staphylococci, which occurs within a few days after intubation. In adult and older children, bronchoalveolar lavage and protected swab specimens have been used successfully. In young children, it is not possible to obtain a protective sample for the size of the required bronchoscope, and the bronchoalveolar lavage performed has a high incidence of contamination. Methods for determining the causative microorganism are positive blood culture that cannot be explained by other sources, positive pleural fluid cultures, and a positive bronchoalveolar lavage sample despite its limitations, >5% of bronchoalveolar lavage cells containing intracellular bacteria and positive


**Table 1.**

*Clinical criteria for diagnosing VAP by age [2].*

pulmonary parenchyma culture. When nosocomial pneumonia is suspected, empirical treatment should be initiated to cover the most likely microorganisms, taking into account hospital resistance. Once the agent is identified, the antibiotic coverage needs to be adjusted [2].

#### **2.2 Prevention of VAP**

In 2004, The Institute for Healthcare Improvement developed a set of evidencebased recommendations for practitioners to reduce mortality. The evidence was based on research in adults.

**25**

*Pseudomonas aeruginosa* as a Cause of Nosocomial Infections

children due to the high risk of unwanted extubation [9].

techniques according to infectious microorganisms

The application of these measures can reduce the incidence of VAP to 45%, although the last 2 points do not directly lead to nosocomial pneumonia, but are designed to treat complications in monitored, sedentary adult patients with ICU. In children, many centers use only low-risk interventions such as raising the head above the bed, considering extubation, and using stress ulcer prophylaxis. Intervention such as omission of sedation is unpredictable and risky in young

Measures often used in pediatric centers focus on specific risk factors [2]:

• measures to prevent iatrogenic spread of infection compliance with good hand hygiene use of general preventive measures use of appropriate isolation

• measures to prevent aspiration of gastric contents elevated head above bed

• measures to improve oral hygiene mouthwashes/cleaning with chlorhexidine

• measures to reduce risk factors of the endotracheal tube use of in-line suction device, where is suitable and available preferential suction of the hypopharynx

• measures to prevent contamination of respiratory equipment single-purpose oropharyngeal suction device prevention of condensate accumulation in the

• measures to reduce the length of mechanical ventilation daily consideration of

Hygiene of hands with alcoholic solutions or soap and water, together with adherence to general precautions and appropriate isolation, are the most effective methods. The raised position of the head prevents aspiration of the stomach contents. The risk of aspiration can be further minimized by decompression of the stomach with a gastric tube and continuous monitoring of the residue. Mouth hygiene is important. The American Dental Association recommends starting continuous oral hygiene in infants before the appearance of dentition. The recommendation for the use of oral swabs and brushing teeth in critically ill patients is based on the fact that the dental plaque consists predominantly of gram-negative

In children, secretion of secretions from the hypopharynx is recommended to prevent VAP. It is recommended that this aspiration be performed prior to aspiration from the endotracheal tube, to prevent aspiration of secretions from the hypopharynx, and prior to manipulation of the endotracheal tube. In some centers, they also aspirate secretions before positioning the patient on the bed. The use of a closed in-line extraction system may not have a direct effect on reducing the incidence of VAP, but may be effective in preventing contamination of the extraction device. Condensed steam in the respiratory circuit can potentially contaminate and theoretically cause infection, so condensate must be removed from the circuit. Staff should be conscientious and avoid contaminating the respirator and its accessories [9]. In the prevention of nosocomial pneumonia, it is important to minimize the length of the patient's mechanical ventilation. The presence of an endotracheal tube poses a risk of VAP and not the positive pressure ventilation associated with it.

respiratory circuit prevention of contamination of respiratory device

extubation attempts interruption of neuromuscular blockade.

bacteria and forms within 48 hours of admission to the ICU [2].

between 30 and 45 degrees monitor/drainage of gastric contents

0.12% use of toothbrush and oral swab in daily oral hygiene

over endotracheal suction and relocation of the ET tube

*DOI: http://dx.doi.org/10.5772/intechopen.95908*

The package of recommendations for VAP in adults includes the following interventions [8]:

a. raising the patient's head above the bed between 30 and 45°,

b.a break in sedation and daily reassessment of extubation,

c.prophylaxis of stress ulcers,

d.prophylaxis of deep vein thrombosis.

*Pseudomonas aeruginosa* - Biofilm Formation, Infections and Treatments

or progressive and persistent infiltrate or consolidate or cavitation that developes later than 48 hrs post initiation of mechanical ventilation

At least one of shaded criteria AND At least two of the non-

If >70 years of age without other recognized cause

New onset or worsening of cough, dyspnea, or

**Cough** Not applicable as separate criteria +

**Chest film** At least 2 serial CXR with new

shaded criteria

recognized cause

**Temperature** >38°C without other

**WBC count** <4000/mm3 OR ˃12,000/ mm3

symptoms

tachypnea

**Additional Criteria**

**Altered mental status**

**Sputum/ Secretions**

**Respiratory Symptoms**

**Auscultation findings**

**Worsening oxygenation or ventilation**

**Table 1.**

**All patients 1-12 year of age <12 months of age**

At least 3 of the criteria below

<4000/mm3 OR ˃>15,000/mm3

New onset purulent sputum OR change in character of sputum OR increased respiratory

Rales or bronchial breath sounds Wheezing, rales, or ronchi

Present Present Required criteria

**Heart rate** Not applicable <100 beats/min OR > 170

Not applicable Not applicable

>38,4°C or <37°C without other recognized

cause

Worsening gas exchange AND at least 3 of the criteria below

˂4000/mm3 OR ˃15,000/mm3 and band forms ˃10%

Apnea, tachypnea, increased work of breathing, or grunting

beats/min

Temperature instability without other recognized cause

pulmonary parenchyma culture. When nosocomial pneumonia is suspected, empirical treatment should be initiated to cover the most likely microorganisms, taking into account hospital resistance. Once the agent is identified, the antibiotic

In 2004, The Institute for Healthcare Improvement developed a set of evidencebased recommendations for practitioners to reduce mortality. The evidence was

The package of recommendations for VAP in adults includes the following

a. raising the patient's head above the bed between 30 and 45°,

b.a break in sedation and daily reassessment of extubation,

coverage needs to be adjusted [2].

*Clinical criteria for diagnosing VAP by age [2].*

**2.2 Prevention of VAP**

based on research in adults.

c.prophylaxis of stress ulcers,

d.prophylaxis of deep vein thrombosis.

interventions [8]:

**24**

The application of these measures can reduce the incidence of VAP to 45%, although the last 2 points do not directly lead to nosocomial pneumonia, but are designed to treat complications in monitored, sedentary adult patients with ICU. In children, many centers use only low-risk interventions such as raising the head above the bed, considering extubation, and using stress ulcer prophylaxis. Intervention such as omission of sedation is unpredictable and risky in young children due to the high risk of unwanted extubation [9].

Measures often used in pediatric centers focus on specific risk factors [2]:


Hygiene of hands with alcoholic solutions or soap and water, together with adherence to general precautions and appropriate isolation, are the most effective methods. The raised position of the head prevents aspiration of the stomach contents. The risk of aspiration can be further minimized by decompression of the stomach with a gastric tube and continuous monitoring of the residue. Mouth hygiene is important. The American Dental Association recommends starting continuous oral hygiene in infants before the appearance of dentition. The recommendation for the use of oral swabs and brushing teeth in critically ill patients is based on the fact that the dental plaque consists predominantly of gram-negative bacteria and forms within 48 hours of admission to the ICU [2].

In children, secretion of secretions from the hypopharynx is recommended to prevent VAP. It is recommended that this aspiration be performed prior to aspiration from the endotracheal tube, to prevent aspiration of secretions from the hypopharynx, and prior to manipulation of the endotracheal tube. In some centers, they also aspirate secretions before positioning the patient on the bed. The use of a closed in-line extraction system may not have a direct effect on reducing the incidence of VAP, but may be effective in preventing contamination of the extraction device. Condensed steam in the respiratory circuit can potentially contaminate and theoretically cause infection, so condensate must be removed from the circuit. Staff should be conscientious and avoid contaminating the respirator and its accessories [9].

In the prevention of nosocomial pneumonia, it is important to minimize the length of the patient's mechanical ventilation. The presence of an endotracheal tube poses a risk of VAP and not the positive pressure ventilation associated with it. Daily consideration is recommended as to whether the patient can be extubated. Discontinuation of sedation is impractical for most children in pediatric ICUs, as it can potentially lead to unwanted extubation, especially in children who are small enough to cooperate or understand the need for intensive care interventions. Studies in adults and children show that the use of non-invasive ventilation in ICU contributes to reducing the incidence of VAP [2].
