Ventilator-associated pneumonia (VAP) increases mortality and hospital stay in mechanically ventilated patients. Two studies found that administering probiotics significantly reduced VAP rates, while one study found no significant effect. Further research is needed to validate the benefits of probiotics and determine which probiotic formulations and patient populations may benefit most from their use in VAP prevention.

1. Running head: REDUCING VAP IN ICU PATIENTS – A CRITICAL ISSUE 1
Reducing Ventilator Associated Pneumonia in ICU Patients – A Critical Issue
Emily Ann Lehnert
University of South Florida

2. REDUCING VAP IN ICU PATIENTS – A CRITICAL ISSUE 2
Abstract
Clinical Problem: Ventilator Associated Pneumonia (VAP) has been correlated with
mortality, increased hospital stay periods, and further complication in patients receiving
mechanical ventilation.
Objective: To determine if daily administration of probiotics will lower the incidence rate
of VAP in mechanical ventilated patients in intensive care units (ICUs). The purpose of
this paper is to analyze if administrating probiotics has a positive effect on reducing VAP
in ICU patients, and if so, are the results significant enough to implement this practice in
standard mechanical ventilator patient care. PubMed and CINHAL were used to
investigate random controlled trials (RCT) that have studied the effects of probiotics of
reducing the incidences of VAP. The key search terms used in these search engine’s were
ventilator associated pneumonia and probiotics.
Results: The Morrow, Kollef & Casale (2010) study found that probiotics had a statistic
significant affect on reducing the incidence of VAP (p=0.007). The Banupiya,
Srinivasaraghavan, Narvayananan and Mandal (2015) study also showed a statistical
significant affect on reducing the incidence of VAP (p<00.1). The Barraud et al. (2010)
study found that administering probiotics did not have enough statistical significance to
conclude that administrating probiotics would decrease VAP incidences (p=0.69). These
studies differ from one another by the types of probiotics that were administrated and
different settings of ICU’s such as the pediatric ICU (PICU) or the adult ICU.
Conclusion: Patients with mechanical ventilators who receive probiotic therapy may have
a reduced rate of acquiring VAP. Further examination of probiotic therapy needs to be
conducted to validate the benefits of VAP in mechanical ventilated patients.

3. REDUCING VAP IN ICU PATIENTS – A CRITICAL ISSUE 3
Reducing Ventilator Associated Pneumonia in ICU Patients - A Critical Issue
Even with the strict procedures of preventative methods and advances in the
medicine field throughout the years, VAP is still recorded to be the second most common
hospital acquired infection (Bo et al., 2014). Current preventative protocols to decrease
the incidences of VAP include, elevating the head of the bed, daily sedation vacations,
peptic ulcer disease prophylaxis, DVT prophylaxis, and daily oral care with
chlorhexidine. However, VAP rates are still very high since implementing this protocol in
2003. When mechanical ventilated patients acquire VAP, studies have shown that their
mortality rate increases by 50% (Barraud et al., 2010). This raises the question of what
better methods are there to prevent the occurrence of VAP. Many study results have
revealed that probiotics can support the gut barrier function that could produce clinical
benefits (Bo et al., 2015). Probiotics also promote the production of vitamins, and support
the immune system by fighting infections and harmful bacteria. In mechanically
ventilated patients in intensive care units how does the administration of probiotics
compared to the absence of probiotic therapy to decrease the incidence of VAP during the
hospital stay?
Literature Search
Search engines used to search for relevant RCT articles about probiotic
prophylaxis to prevent VAP include, PubMed and CINAHL. The key search terms used
in these search engines include: ventilator associated pneumonia, and probiotics.
Literature Review
Three randomized controlled trails and one guideline were used to evaluate the
administration of probiotics and their influence on decreasing the incidence rate of

4. REDUCING VAP IN ICU PATIENTS – A CRITICAL ISSUE 4
VAP. Using a blinded randomized control trial, Morrow, Kollef, & Casale (2010)
investigated probiotic prophylaxis of VAP. The goal of the study is to determine if
administering probiotics would decrease the incidence of VAP. Study criteria
included adults 19 years old or older with a 95% chance that the patient would need
mechanical ventilation support for at least 72 hours. Out of 138 participants, 68
participants were placed in the intervention group and 70 participants were placed
in the placebo group. Patients in the study group received probiotic therapy and
were administered Lactobacillus rhamnosus GG twice daily. In this intervention
group, 13 participants were diagnosed with VAP. In the placebo group, 28
participants were diagnosed with VAP. Patients who were administered probiotics
had less incidences of VAP compared to the patients who were administered a
placebo by a p-value of 0.007. The study concluded that administering probiotics
was correlated with reducing incidences of VAP. A strength of this study was the
blinded randomized control trial. A design weakness of this study was that it had a
limited sample size and that the study only used one specific type of probiotic.
Using an open-label randomized control trial, Banupiya, Biswal,
Srinivasaraghavan, Narayanan & Mandal (2015) investigated probiotic prophylaxis
to prevent VAP in children on mechanical ventilation. The goal of the study was to
establish if the use of probiotic administration would decrease the rate of acquiring
VAP during the length of hospital stay in the PICU. The patient population in the
study consisted of patients under the age of 12 who were predicted to be on a
ventilator for at least 48 hours. The study included 150 participants, 75 participants
were placed in the intervention group and 75 participants were placed in the

5. REDUCING VAP IN ICU PATIENTS – A CRITICAL ISSUE 5
control group. Participants in the intervention group received one capsule of
probiotics twice a day in the ICU for seven days or until discharge. The probiotic
capsules given in the study included Lactobacillus, Bifidobacterium, and
Streptococcus thermophiles. The study results found that the participants in the
intervention group had a lower incidence of VAP compared to the control group,
(p<00.1, 17.1% in the intervention group, 48.6% in the control group). The strength
of this study is that it included the use of a computer generated randomized number
list to place the participants in their selected groups. Their diseases and background
were not considered leaving no room for bias. The weakness of this study was that it
was done on a very specific age group so the results may not be applicable to a
larger scale of patients.
Using a double blind, randomized, placebo-controlled trial, Barraud et al.
(2010) investigated probiotics in the critically ill patients. The goal was to find how
the administration of probiotics affected ventilated patients. Study criteria included
all intubated adult patients undergoing mechanical ventilation for at least two days.
Patients were randomly assigned to the probiotics or placebo group by using a
concealed randomization table. Study consisted of 167 participants. Eighty-seven
participants were in the probiotic group, and 80 participants were in the placebo
group. Treatment consisted of five Ergyphilus capsules (A combination of
Lactobacillus rhamnosus GG, Lactobacillus casei, Lactobacillus acidophilus and
Bifidobacterium bifidum) or a placebo capsule administered once daily. The study
concluded that there were no observed protective results from administering
probiotics in critically ill ventilated patients. The results were not statistically

6. REDUCING VAP IN ICU PATIENTS – A CRITICAL ISSUE 6
significant between the probiotic group and the placebo group with a p-value of
0.68. The strength of the study was the randomized double blind design with
placebo-controlled administration. The weakness of the study was that there was
room for bias with a pharmacist using a randomized table technique randomly
assigned patients to either the placebo or intervention group. Using a computerized
program would have been a better option for this study to ensure randomization.
The guidelines for the prevention of VAP by the American Association of
Critical Care Nurses (2014) are described as evidence-based interventions that
would help prevent VAP. The AACN recommends that the patient has an elevated
head of bed (HOB), daily sedation vacations, peptic ulcer disease prophylaxis, deep
vein thrombosis prophylaxis and daily oral care with chlorhexidine. These
interventions should be implemented together for better outcomes.
Synthesis
Morrow et al. (2010) demonstrated that the overall VAP rate had a
statistically significant decrease when probiotics were administered (p=0.007).
Furthermore, Banupiya et al. (2015) showed statistical evidence of reduced rates of
VAP when probiotics were administered (p<00.1). Among the studies researched,
Barraud et al. (2010) was the only study that didn’t find statistically significant
evidence that administering probiotics was beneficial in reducing the incidence rate
of VAP (p=0.69). Finally, The AACN (2014) guideline currently does not include
administration or probiotics as a preventative measure, but does suggest a plethora
of other interventions.

7. REDUCING VAP IN ICU PATIENTS – A CRITICAL ISSUE 7
Research shows that probiotics have the potential to benefit patients on
mechanical ventilation in order to prevent incidences of VAP. However, in order to
implement probiotics in practice, there needs to be more studies having statistically
significant results from probiotic administration. More research needs to be
implemented to see if probiotics should be added to the VAP prevention bundle
guidelines and if probiotics are beneficial in all patients in all ICU settings.
Clinical Recommendations
The AACN (2014) guidelines demonstrates that to prevent VAP, nurses
should implement interventions such as elevating the patient’s head of bed (HOB),
daily sedation vacations, peptic ulcer disease prophylaxis, deep vein thrombosis
prophylaxis and daily oral care with chlorhexidine. The AACN also suggests to
implement these intervention together for optimal effect. Supplemental research
needs to be conducted to evaluate whether or not the administration of probiotics
should be apart of the VAP prevention bundle and practiced on an everyday basis in
the hospital ICU’s with mechanically ventilated patients. Probiotic administration
could be another way to prevent the incidence of VAP in patients if further
investigated.

8. REDUCING VAP IN ICU PATIENTS – A CRITICAL ISSUE 8
References
Banupiya, 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 control trial.
Intensive Care Medicine, 41, 677-685. doi: 10.1007/s00134-015-3694-4.
Barraud, D., Blard, C., Hein, F., Marcon, O., Cravoisy, A., Nace, L., . . . Gibot, S. (2010).
Probiotics in the critically ill patient: A double blind, randomized, placebo-
controlled trial. Intensive Care Medicine, 36, 1540-1547. doi:
10.1007/s00134-010-1927-0.
Bo, L., Li, J., Tao, T., Bai, Y., Ye, X., . . . Deng, X. (2014) Probiotics for preventing
ventilator-associated pneumonia. Cochrane Database of Systematic Reviews, 10.
doi: 10.1002/14651858.CD009066.pub2.
Morrow, L. E., Kollef, M. H., & Casale, T. B. (2010). Probiotic prophylaxis of
ventilator-associated pneumonia: A blinded, randomized, controlled trial.
American Journal of Respiratory and Critical Care Medicine, 182(8), 1058–
1064. doi: 10.1164/rccm.200912-1853OC.
Munro, N., & Ruggiero, M. (2014). Ventilator-associated pneumonia bundle:
Reconstruction for best care. AACN Advanced Critical Care, 25, 163-175. doi:
10.1097/NCI.0000000000000019