(1315) Ventilator Bundle Adherence and VAP in Low-/Middle- and High-Income Countries: A Multicentric Study

Introduction: Ventilator-associated pneumonia (VAP) poses a significant risk to patients in intensive care units (ICUs). Implementing ventilator bundles has reduced VAP rates in high-income countries (HICs), but their effectiveness in low- and middle-income countries (LMICs) remains unclear. This study compares ventilator bundle adherence and its impact on VAP rates in LMICs and HICs.

Methods: We performed a secondary analysis of the CERTAIN study dataset, which evaluated the impact of a clinical decision support tool in 34 ICUs across ten LMICs and five HICs from 2013 to 2017. Patients from the pre- and post-CERTAIN intervention phases who were mechanically ventilated for at least 48 hours were included. Those younger than 18 years, not critically ill, re-admitted, or transferred from an outside hospital were excluded. The ventilator bundle consisted of daily (1) oral care, (2) head-of-bed elevation, (3) spontaneous breathing assessment, and (4) sedation evaluation. The average number of completed components was used to calculate a bundle adherence index, indicating compliance levels. The primary outcome was VAP development.

Results: 1,755 patients from LMICs and 498 from HICs were included. Patients from LMICs were younger (median age 62.1 vs. 65.9 years, p = 0.001) and more often male (63% vs. 57%, p = 0.018). LMIC patients had lower comorbidity rates (87% vs. 94%, p < 0.001) but higher disease severity at admission (median Sequential Organ Failure Assessment score of 9 vs. 7, p < 0.001). The median ventilator bundle adherence index was significantly lower in LMICs (0.75 vs. 0.89, p < 0.001). After adjusting for ventilator bundle adherence, baseline conditions, severity of illness, duration of mechanical ventilation, and CERTAIN study intervention status, ICU admission in LMICs was associated with a higher risk of VAP compared to HICs (aOR 2.11, 95% CI 1.34-3.32).

Conclusions: LMICs have lower levels of adherence to the ventilator bundle compared to HICs. Being in an LMIC is associated with more than double the risk of VAP compared to HICs, independent of ventilator bundle adherence. Unmeasured variables such as ICU infrastructure, staffing, and handwashing practices might be responsible for the higher rates of VAP in LMICs.