Running head: A CHANGE IN PRACTICE

A Change in Practice:
The Prevention of Ventilator Associated Pneumonia using Probiotics
Sean Briceno
University of South Florida

A CHANGE IN PRACTICE

The Prevention of Ventilator Associated Pneumonia using Probiotics

Patients who are critically ill and require mechanical ventilation have a high morbidity and are
more prone to infections. Ventilator associated pneumonia (VAP) is a common infection that
patients on mechanical ventilators can acquire. The incidence of VAP has shown to increase
patients mortality by 33-50% depending on the patients underlying medical illness (Kalanuria,
Zai, & Mirski 2014). Decreasing the chance of VAP can increased the survivability of patients
who require mechanical ventilation. Ventilator associated pneumonia is a serious medical
condition that negatively impacts the health of patients that require ventilator assistance.
Ventilator associated pneumonia can be prevented by taking the necessary precaution when
caring for a patient on a ventilator. In critical care patients that require ventilation how does the
administration of probiotics compare with standard ventilation affect the chance of acquiring
ventilator associated pneumonia over the duration their hospitalization? With the addition of
probiotics, the percent of ventilator associated pneumonia should decrease in the population.
Literature Search
The search engines CINHAL and PubMed were used by searching the terms, ventilator
associated pneumonia, VAP, probiotics and prevention. During the search, limits were set for
only randomized controlled trials that had been published since 2009. A total of three peer
reviewed randomized controlled trails and one guideline published by the Institute for Clinical
Systems Improvement (ICSI) were chosen to be reviewed and synthesized.
Synthesis
Banuprriya, Biswal, Srinivasaraghavan, Narayanan, and Mandal (2015) showed that
children who were mechanically ventilated had significantly lower occurrence of VAP in contrast
to the control group (p=0.02). They administered a probiotic prophylaxis along with the standard

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care for children on mechanical ventilation to their intervention group and the control group only
received the standard care. The mean duration of hospital stay was significantly shorter in the
intervention group compared to the control group, with the mean being 13.13 days for the
intervention group and 19.17 days for the control group (p=0.001). There was no significant
difference in mortality between the two groups. Giamarellos-Bourboulis, Bengmark,
Kanellakopoulou, and Kotzampassi (2009) showed that patients in the intervention group had
significantly less occurrences of VAP (p=0.047). Their results also showed that sepsis occurred
less in patients in the intervention group (p=0.028). The participants were randomly dispersed
into two different groups the intervention group and the control group. The intervention group
received the Synbiotic 2000FORTE and the standard care for patients on a mechanical ventilator
were as the control group received a placebo and the standard care. Marrow, Kollef, and Casale
(2010) result showed that there was a significantly less occurrence of VAP in the intervention
group compared to the control group (p=0.007). The participants were randomly assigned into
two different groups the intervention group and the control group. The intervention group
received the probiotic prophylaxis and the standard care for patients on a mechanical ventilator
were as the control group only received the standard care and a placebo.
While each of these three studies compared the probiotics group with the standard care
group, differences between the three studies were observed. One notable difference between the
studies was the selected sample criteria. In the study conducted by Banuprriya et al. (2015) the
sample criteria were children no older than 12 years old who were admitted to the PICU and who
were likely to need mechanical ventilation for more than 48 hours. Giamarellos-Bourboulis,
Bengmark, Kanellakopoulou, and Kotzampassi (2009) sample criteria were patients who had
multiple organ injuries and needed emergency tracheal intubation and ventilation. Marrow,

A CHANGE IN PRACTICE

Kollef, and Casale (2010) sample criteria was mechanically ventilated patients who were at least
19 years old and were at high risk for developing VAP.
While the reviewed research shows that probiotics can significantly reduce the incidences
of ventilator associated pneumonia (VAP), further evidences will be need to allow for probiotics
to be incorporated into the standard of practice. Some gaps that the current research has a lack of
evidence on is as follows: the population that who benefit the most from probiotics, if probiotics
could be harmful to patients with certain underlying medical conditions and the role that
probiotic play on patients who have VAP.
Proposed Practice Change
The uses of probiotic prophylaxis in patients on mechanical ventilator is a safe and
effective intervention for prevention of ventilator associated pneumonia. When caring for a
patient on a ventilator, probiotic prophylaxis has been shown to significantly reduce the
occurrence of VAP. Probiotic prophylaxis can easily be integrated into the standard care for
patients on a mechanical ventilator in hospitals such as Florida Hospital Tampa and other
organizations as an added measure of prevention.
Implications for Practice
A nurses role in evidence base practice is to research ways to improve interventions that
can help decrease morbidity and mortality. Nurses should also implement current EBP when
caring for patients in the clinical setting with the uses of evidence based practice models.
Evidence based practice models are used to help nurses move evidence into practice. The use of
an EBP model leads to organized approach to evidence based practice and can prevent
incomplete implementation. With the use of an EBP model, nurses will be able to dramatically
decrease the rate of VAP in patients requiring mechanical ventilation.

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Ethical Considerations

There are many ethical principles that apply to practice change and how clinicians use
those principles to guide practice. The first ethical principle is that the research muse have some
social or scientific value and as such the patient must benefit as a result of implementing EBP.
Another ethical principle is scientific validity. The EBP should be as scientifically valid as
possible without wasting resources. Lastly when implementing EBP there must be fair subject
selection. The health care team needs to be able to implement the EBP to all patients that would
benefit from the research. Administering probiotic prophylaxis can easily be implemented into
standard care for patients on mechanical ventilators. The nurse will be able to administer the
probiotics when they distribute there morning medications.
In conclusion, there is strong evidence that supports administering a probiotic
prophylactic to patients on a mechanical ventilator to prevent VAP. Administering probiotic
prophylactics can decrease the chance of VAP, decrease the morbidity and mortality rates, and
can decrease the time spent in the hospital. Standard care for patients with VAP should change to
include the use of a probiotic to help reduce the risk of developing VAP.

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6
References

Banuprriya, B., Biswal, N., Srinivasaraghavan, R., Narayanan, P., & Mandal, J. (2015). Probiotic
prophylaxis to prevent ventilator associated pneumonia (VAP) in children on mechanical
ventilation: An open-label randomized controlled trail. Intensive Care Medicine, 41(4),
677-685. doi: 10.1007/s00134-015-3694-4.
Giamarellos-Bourboulis, J., Bengmark, S., Kanellakopoulou, K., & Kotzampassi, K. (2009). Proand synbiotics to control inflammation and infection in patients with multiple injuries.
The Journal of Trauma: Injury, Infection, and Critical Care, 67(4), 815-821. doi:
10.1097/TA.0b013e31819d979e
Institute for Clinical Systems Improvement. (2011). Prevention of ventilator-associated
pneumonia. Health care protocol. Bloomington (MN): Institute for Clinical Systems
Improvement (ICSI)
Kalanuria, A., Zai, W., & Mirski, M. (2014). Ventilator-associated pneumonia in the ICU.
Intensive Care and Emergency Medicine, 18(2), 208. doi: 10.1186/cc13775
Marrow, L., Kollef, M., & Casale, T. (2010). Probiotic prophylaxis of ventilator-associated
pneumonia. American Journal of Respiratory and Critical Care Medicine, 182(8), 10581064. doi: 10.1164/rccm.200912-1853OC