Nursing Journal Volume 10.
Issue 1.
Page 33 Ae 41 e-ISSN: 2354-6050 https://ejurnal.
id/index.
php/JKep/ DOI: https://doi.
org/10.
32668/jkep.
ANALYSIS OF MODIFIABLE FACTORS ASSOCIATED WITH
VENTILATOR-ASSOCIATED PNEUMONIA IN MECHANICALLY
VENTILATED PATIENTS IN ICU
Abstract 1 Nabiila Puspitasari Ventilator-associated pneumonia (VAP) is reported as one of the highest nosocomial infection conditions in several countries.
Risk factors can be classified into modifiable and non-modifiable factor.
This study aims to analyze modifiable factors related to the incidence of VAP in patients using mechanical ventilation.
This study used a prospective cohort observational analytic design with a quantitative involving 40 patients with mechanical ventilation in the ICU and selected using purposive sampling.
Observation sheets and Clinical Pulmonary Infection Score (CPIS) were used as data collection tools.
Hypothesis testing in this study utilized SomersAos d, contingency coefficient, and KendallAos tau.
The analysis revealed significant associations between the duration of mechanical ventilation .
=0.
, and level of consciousness .
=0.
with the incidence of VAP.
However, no significant associations were found between antibiotic use .
=0.
ICU
length of stay .
=0.
, and reintubation .
=0.
with the incidence of VAP.
The study showed that the length of time mechanical ventilation was used and the patient's level of consciousness were factors associated with the incidence of VAP in the ICU.
Thus, special attention to modifiable factors can be one of the effective strategies in reducing the incidence of VAP in the ICU.
2nd Rycco Darmareja1* Department of Nursing.
Faculty of Health Science.
Universitas Pembangunan Nasional AuVeteranAy Jakarta.
Jakarta.
Indonesia email: ryccodarmareja@upnvj.
Keywords:
Intensive Care Unit.
Mechanical Ventilation Modifiable Factors Ventilator-Associated Pneumonia Received: February 2025 Accepted: March 2025 Published: May 2025 A year The Authors.
Published by Published Jurusan Keperawatan.
Politeknik Kesehatan Kemenkes Jakarta i.
This is Open Access article under the CC-BY-SA License .
ttp://creativecommons.
org/licenses/by-sa/4.
0/).
DOI:
https://doi.
org/10.
32668/jkep.
VAP can be caused by both non-Multi Drug
INTRODUCTION
Nosocomial infections, also referred to as healthcareassociated (HAI.
, environments such as hospitals, intensive care units (ICU.
, and hospices1,2.
These infections are frequently associated with the use of invasive medical devices, including Ventilator-Associated Pneumonia (VAP)3.
Data from the International Nosocomial Infection Control Consortium (INICC) reported the incidence of nosocomial infections in 45 countries from 2013 to 2018, 12,085 cases of VAP.
VAP, a type of nosocomial infection, typically occurs after more than 48 hours of Resistant (MDR) pathogens, such as Streptococcus Methicillin-Sensitive Staphylococcus aureus (MSSA), or Pseudomonas aeruginosa, as well as MDR pathogens and Gram-positive bacteria such as Methicillin-Resistant Staphylococcus aureus (MRSA)5.
The International Nosocomial Infection Control Consortium (INICC) reported a substantial decline in VAP cases, decreasing from 100,660 in 2016 to 32,216 in 2019 and 24,170 in 20216,7.
The incidence of VAP across 22 Asian countries, reporting incidences of 18.
2, and 9.
0 per 1,000 ventilation days in low-income, upper-middle, and high-income countries, respectively8.
mechanical ventilation 4.
Specific data on VAP incidence have not been included VAP is a type of nosocomial infection, typically occurs in the Indonesian Health Profile or the Basic Health Research reports9,10.
The incidence report of VAP in the JKEP (Jurnal Keperawata.
Vol 10 Issue 1.
May 2025.
Page 33-41 Intensive Unit Care (ICU) of RSUD Dr.
Soetomo showed a rate of 3.
2 per 1,000 days of ventilator use in 2019, and 1.
2 per 1,000 days of ventilator use in 2020
e-ISSN: 2354-6050
METHOD
This study employed a prospective cohort observational analytic design with a quantitative approach.
The study population comprised patients receiving mechanical Modifiable risk factors for VAP include the use of ventilation in the ICU at one of the type B regional nasogastric tubes, the use of immunosuppressive agents, public hospital in Jakarta.
A total of 40 mechanically mechanical ventilation lasting more than 48 hours, ventilated patients in the ICU participated in the study.
proton pump inhibitors (PPI.
, tracheostomy, and The sample size is determined based on the sample transfusion of more than two units of blood products .
calculation results from an unknown population Significant risk factors for VAP identified in previous .
npatients with uncertain variation.
so that a formula studies include reintubation .
1% in early onset and is used based on the proportion of the population in 24% in late onse.
, nasogastric feeding .
9% in early previous studies with an additional patient of 10%.
The onset and 93.
3% in late onse.
, proton pump inhibitors sampling method employed was non-probability .
3% in early onset and 94.
7% in late onse.
, and prior sampling, specifically purposive sampling, based on antibiotic use .
6% in early onset and 86.
7% in late predefined inclusion and exclusion criteria.
The Inclusion criteria encompassed patients who are A preliminary study, conducted through interviews on attached to mechanical ventilation for <48 hours with September 19 and September 30, 2024, revealed that the the ETT method, patients aged >18 years, who get a duration of mechanical ventilation ranged from 2 to 30 VAP Bundle in the form of oral hygiene three times a days, while the length of ICU stay varied from 2 days to day, semi-recumbent sleep position, suction, and 3 months.
The most commonly used method of maintain cuff tube pressure 20 cmH2O, and patients get mechanical ventilation is Endotracheal Tube (ETT).
PPI drugs .
meprazole 2 x 40 m.
which are evaluated Some patients in the ICU had experienced reintubation based on nursing action notes in medical records.
1-2 times.
All patients received treatment in the form of Exclusion PPIs and antibiotics, and were fitted with NGTs.
In the experienced VAP before the implementation of the past month, 15 cases of VAP were reported in ICU 1, study and the patient's family was not willing to give while instances of VAP in ICUs 2 and 3 were consent to make the patient a research respondent 12,14.
infrequently recorded.
This hospital has implemented a VAP Bundle policy consisting of 14 actions, with monitoring carried out three times a day on each shift.
Several actions in the VAP bundle, such as oral hygiene 3 times a day, semi-recumbent sleeping position, suction per 2-4 hours, and maintaining a cuff tube pressure of 20 cmH20 were consistently applied in all three ICUs.
The background description above underscores that understanding the risk factors associated with VAP is crucial to strengthening prevention and control efforts.
This study examines the association between modifiable risk factors for VAP in patients attached to mechanical ventilation in the ICU.
The research was conducted in a type B regional public hospitals located in Jakarta from November to December 2024.
The researcher obtained ethical approval at a type B hospital in Jakarta on October 28, 2024, as evidenced by Ethical Clearance Letter No.
095/KEPK.
RSUDT/2024.
Clear and comprehensive information was provided to the participants regarding the research objectives, procedures, potential risks, and Participants were also given the opportunity to make an informed decision and signed an informed consent form.
Data collection was conducted using instruments and The JKEP (Jurnal Keperawata.
Vol 10 Issue 1.
May 2025.
Page 33-41 e-ISSN: 2354-6050 observation sheets and the standardized Clinical Pulmonary Infection Score (CPIS) .
The CPIS has been widely used in clinical practice as an attempt to improve the diagnosis of VAP.
The validity value of this instrument showed the Area Under Curve (AUC) curve analysis reached 0.
76 in the derivation cohort and 0.
in the validation cohort.
The sensitivity of CPIS for Variable Gender Male Female Total Frequency .
Percentage (%) Table 1 shows results of the study of 40 respondents showed that Most .
5%) of the respondents were in the advanced adult category (>60 years ol.
and female.
diagnosing VAP was reported at 45%, while the specificity was 89% when using CPIS cut-off points Ou Table 2 Frequency Distribution of Respondents Based This shows that CPIS is sensitive enough to identify on Duration of Mechanical Ventilation Use.
Level of VAP patients16.
Consciousness.
Antibiotic Use, and Reintubation The observation sheets were used to record and analyze the relationship between modifiable risk factors and the incidence of VAP during ICU treatment.
Patients were observed for a period of 5 days.
This study employed correlative non-parametric hypothesis analysis to assess the relationship between variables.
The statistical tests used included SomersAo d.
Contingency Coefficient, and Kendall Tau.
In this study, ordinal-scale independent and dependent variables, such as oral hygiene frequency, level of consciousness, reintubation, and age, were analyzed in relation to the incidence of VAP using the Somers' d test.
Meanwhile, nominal-scale antibiotic use and gender, were analyzed against the ordinal-scale dependent variable related to VAP Variable Duration of Mechanical Ventilation Use <48 hours Ou48 hours Total Level of Consciousness Coma Soporcoma Sopor Somnolent Apathy Compos Mentis Total Antibiotic Usage Cephalosporin Generation i Cephalosporin Generation IV Beta-Lactam Total Reintubation Reintubated Not Reintubated Total Frequency .
Percentage (%) incidence using the Contingency Coefficient test17.
The study involving 40 respondents revealed that almost Additionally, ratio-scale independent variables were all .
%) respondents used mechanical ventilation for analyzed against the ordinal-scale dependent variable Ou48 hours.
Judging from the level of consciousness, related to VAP incidence using KendallAos Tau test18.
almost half .
5%) were in a Compos Mentis condition.
In terms of antibiotic use, half .
%) received betalactams.
Almost all respondents .
5%) did not RESULTS AND DISCUSSION Frequency characteristics, modifiable VAP risk factors, and VAP incidence Table 1 Frequency Distribution of Respondents Based on Age and Gender Variable Age Advanced Adults: >60 years Middle Adult: 41-60 years Adulthood: 21-40 years old Total Frequency .
Percentage (%) experience reintubation.
Table 3 Distribution of Median Respondents Based on Length of Stay ICU Variable (Da.
Length Of Stay Mean A SD 08 A 2.
Median (Min-Ma.
95% CI Lower Upper Table 3 shows that the length of ICU stay among respondents during data collection ranged from a JKEP (Jurnal Keperawata.
Vol 10 Issue 1.
May 2025.
Page 33-41 e-ISSN: 2354-6050 minimum of 5 days to a maximum of 13 days, with a highlighted that prolonged mechanical ventilation median duration of 5 days.
increases exposure to nosocomial risks during Another study showed that duration Table 4 Frequency Distribution of VAP Incidence Frequency .
Incidence of VAP VAP (CPIS Score Ou .
No VAP (CPIS Score <.
Total Percentage (%) Table 4 shows the incidence of VAP in 40 respondents.
Most .
%) of the respondents, namely 28 people, did of mechanical ventilation significantly increased the risk of VAP, with a p-value of 0.
Prolonged mechanical ventilation is recognized as a major risk factor for VAP, as prolonged use facilitates bacterial colonization and subsequent infection 11.
not experience VAP, while the remaining 12 Other studies have also shown no significant respondents .
%) experienced VAP.
association between the duration of mechanical ventilation and the incidence of VAP attributed to the Relationship between Duration of Mechanical implementation of a VAP prevention package.
Ventilation Use and the Incidence of VAP including maintaining the head of the bed at Ou30A.
Table 5 Analysis of the Relationship between the ensuring proper oral hygiene, and optimizing secretion Duration of Mechanical Ventilation Use and the management, which can effectively reduce the risk of Incidence of VAP in Patients Installed with Mechanical VAP even with prolonged mechanical ventilation20.
Ventilation in the ICU .
Duration Incidence of VAP
Total
VAP
No VAP Mechanica Ventilation Use <48 25 8 100 Ou48 6 18,8 26 81,2 32 100 Relationship between Level of Consciousness and the Incidence of VAP p-value Consciousness and the Incidence of VAP in Patients Installed with Mechanical Ventilation in the ICU 0,009 Table 5 shows that most respondents .
%) with Table 6 Analysis of the Relationship between Level of <48 experienced VAP.
Meanwhile, a small proportion .
8%) of respondents with mechanical ventilation duration Ou48 hours experienced VAP.
SomersAo d test yielded a p-value of 0.
009 (<0.
, indicating a .
Level Consiousness Coma
Soporcoma
Sopor
Somnolent Apathetic Compos Mentis Incidence of VAP
Total
pVAP
VAP
1 11,1 8 88,9 9 100 0,021 0,239
1 16,7 5 83,3 6 100
2 18,2 9 81,8 11 100
significant association between mechanical ventilation duration and VAP incidence.
The r-value .
of 563 suggests a moderate positive correlation, meaning that a longer duration of mechanical ventilation is associated with a higher incidence of VAP.
Table 6 illustrates that all patients .
%) with coma and half .
%) of those with soporcoma and sopor developed VAP.
In contrast, the majority .
8%) of patients with a compos mentis level of consciousness did not experience VAP.
SomersAo d analysis yielded a p-value of 0.
021 (<0.
This finding is in line with the results of a previous study that reported a significant association between the duration of mechanical ventilation and the incidence of VAP .
-value = 0.
Their study and an r-value of 0.
239, indicating a weak positive correlation between the level of consciousness and VAP incidence.
This suggests that a decline in a patientAos level of consciousness is associated with a JKEP (Jurnal Keperawata.
Vol 10 Issue 1.
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Page 33-41 e-ISSN: 2354-6050 higher likelihood of developing VAP.
VAP, with a p-value of 0.
The most commonly used Several studies have shown a significant correlation antibiotic in the VAP group was a third-generation between decreased level of consciousness and cephalosporin .
9%) 11.
increased risk of VAP with a p-value of <0.
Low ICU patients are often given prophylactic antibiotics to level of consciousness, especially coma, as a prevent nosocomial contributing factor to VAP, with a p-value of 0.
Impaired especially when undergoing invasive procedures such as surgery or insertion of invasive devices .
ETT or chest physiological reflexes such as swallowing and The primary objective of prophylactic coughing, increasing the risk of aspiration and airway antibiotic administration is to minimize the risk of This condition facilitates the entry of infection by preventing the colonization of pathogenic food, fluid, or bacteria into the lower respiratory tract.
Additionally, these antibiotics play a 23,24 vital role in reducing the incidence of surgical site Researchers argue that patients with low levels of infections and other complications related to invasive consciousness are more prone to aspiration and device use 25.
In mechanically ventilated patients, the bacterial entry into the lower respiratory tract, which appropriate use of prophylactic antibiotics can help is a major factor in the pathogenesis of VAP.
reduce the risk of nosocomial infections, such as VAP, which is a major contributing factor to VAP even in cases of prolonged ventilation.
Beta-lactam Relationship between Antibiotic Use and the antibiotics are commonly used as prophylaxis in Incidence of VAP patients at high risk of nosocomial infections 26.
Table 7 Analysis of the Relationship between Antibiotic Use and the Incidence of VAP in Patients Installed with Mechanical Ventilation in the ICU .
Antibiotic Use Cephalosporin
Generation i Cephalosporin
Generation IV
Beta-Lactam
Incidence of VAP
VAP
No VAP
4 22,2 14 77,8
However, generation II and IV cephalosporins which have a very broad spectrum, their use is not recommended as prophylaxis due to the increased risk Total of resistance Therefore, these generations of cephalosporins are more commonly used for therapy than for prophylaxis.
0,339
Table 7 shows that the almost all of patients receiving third-generation cephalosporins .
8%) and betalactam antibiotics .
%) did not develop VAP.
The contingency coefficient test yielded a p-value of 0.
(>0.
, indicating no significant association between antibiotic use and VAP incidence.
Prior antibiotic therapy may disrupt the balance of the respiratory tract microbiome, creating an environment conducive to the growth of pathogens that cause VAP.
Long-term antibiotic use during treatment also contributes to increased antibiotic resistance in VAPcausing bacteria 23,28.
The distribution of patients in the VAP and No VAP groups was uneven, especially because the number of IV-generation cephalosporins was small and all of them experienced VAP, making the This is in line with reports that beta-lactams are often statistical analysis less sensitive in detecting the true given in cases of VAP .
%)13.
A study reported among relationship between the variables.
In addition, the patients who experienced VAP, beta-lactam antibiotics incidence of VAP is not only influenced by the use of were the most commonly used .
%), followed by antibiotic types, but also by other factors, such as third-generation cephalosporins .
2%).
Hypothesis duration of mechanical ventilator use, level of analysis in the study also showed no significant consciousness, and age.
relationship between antibiotic use and the incidence of JKEP (Jurnal Keperawata.
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Page 33-41 Relationship Reintubation e-ISSN: 2354-6050 patients who experienced reintubation and VAP was very small, only 2 out of a total of 40 respondents, so Incidence of VAP Table 8 Analysis of the Relationship between Reintubation and the Incidence of VAP in Patients Installed with Mechanical Ventilation in the ICU .
Incidence of VAP Total p-value r
Reintubation VAP
No VAP
f % f
% f % Reintubated 2 66, 1
33, 3 100
0,253 0,396
Not 10 27 27 73 37 100 Reintubated the variation in data was limited and not enough to show a strong association between reintubation and VAP incidence.
Relationship between Length of Stay ICU and the Incidence of VAP Table 9 Analysis of the Relationship between Length of Stay ICU and the Incidence of VAP in Patients Installed with Mechanical Ventilation in the ICU .
Variable Table 8 indicates that the most .
7%) of respondents who underwent reintubation developed VAP, while Incidence of VAP nearly all .
%) of those who did not undergo Length of Stay ICU p-value 0,135 0,227 reintubation did not experience VAP.
The results of SomersAo d test yielded a p-value of 0.
253 (>0.
In Table 9, the Kendall tau test results indicated a pvalue of 0.
135 (>0.
, suggesting no significant association between ICU length of stay and the VAP reintubation and VAP incidence.
Contrary to a study report that showed a pA study reported no significant association between value of <0.
001, indicating a statistically significant reintubation and VAP .
=0.
This is because difference in ICU length of stay between VAP and researchers only analyzed the first episode of VAP to non-VAP patients.
Their study showed that VAP more clearly identify factors contributing to VAP29.
patients tended to have longer ICU stays compared to line with another study report, only 30% of reintubated those without VAP patients experienced VAP, indicating that reintubation identified a significant correlation between ICU length is not directly associated with VAP 22.
Different results of stay and incidence of VAP, with a p-value of suggested that there was a significant relationship Similarly, another study between reintubation and the incidence of VAP .
= The proportion of patients who experienced reintubation was higher in the VAP group .
%) compared to the non-VAP group .
5%).
This indicates that reintubation contributes as a risk factor Patients who are treated for a long time in the ICU often undergo various medical procedures, such as intubation and tracheostomy, which can increase the risk of infection.
Each invasive procedure carries additional risks for contamination and infection 11.
for VAP 30.
long stay in the ICU may increase the risk of microbial Reintubation refers to the reinsertion colonization in the respiratory tract.
With a longer endotracheal tube in patients who experience time, there is a greater chance for pathogenic extubation failure.
Patients requiring reintubation are microorganisms to colonize the respiratory tract, at an increased risk of developing VAP which may contribute to the development of VAP 4.
Reintubation may increase the risk of aspiration and bacterial colonization in the respiratory tract which facilitates infection and subsequently elevates the risk of VAP 4.
In this study, there no significant association between reintubation and VAP because the number of The findings of our study do not follow the above theory because the researcher restricted observing patients to the 5th day.
This caused most patients to have a total number of treatment days of 5 days.
In other words, the JKEP (Jurnal Keperawata.
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May 2025.
Page 33-41 e-ISSN: 2354-6050 variation of data on this variable is uneven so statistical permission for data collection.
Thanks also go to the analysis becomes less sensitive in detecting the true participants who have been willing to contribute to the relationship between variables.
In addition, the achievement of the objectives of the research conducted.
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Modifiable risk factors associated with VAP and ICU length of stay were not significantly correlation with VAP.
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ACKNOWLEDGMENT