Background and Aims: Neonatal ventilator associated pneumonia (VAP) is a common nosocomial infection and a frequent reason for empirical antibiotic therapy in NICUs. Nonetheless, there is no international consensus regarding diagnostic criteria and management. In a first step, we analyzed the used diagnostic criteria, risk factors and therapeutic management of neonatal VAP by a literature review. In a second step, we aimed to compare suspected vs. confirmed neonatal VAP episodes in our unit according to different published criteria and to analyze interrater-reliability of chest x-rays. Additionally, we aimed to evaluate the development of VAP incidence and antibiotic use after implementation of multifaceted quality improvement changes regarding antimicrobial stewardship and infection control (VAP-prevention-bundle, early-extubation policy, antimicrobial stewardship rounds). Methods: Neonates until 44 weeks of gestation with suspected VAP, hospitalized at our level-III NICU in Lucerne from September 2014 to December 2017 were enrolled. VAP episodes were analyzed according to 4 diagnostic frameworks. Agreement regarding chest x-ray interpretation done by 10 senior physicians was assessed. Annual incidence of suspected and confirmed neonatal VAP episodes and antibiotic days were calculated and compared for the years 2015, 2016, and 2017. Results: 17 studies were identified in our literature review. Overall, CDC-guidelines or similar criteria, requesting radiographic changes as main criteria, are mostly used. Comparison of suspected vs. confirmed neonatal VAP episodes showed a great variance (20.4 vs. 4.5/1,000 ventilator-days). The interrater-reliability of x-ray interpretation was poor (intra-class correlation 0.25). Implemented changes resulted in a gradual decline in annual VAP incidence and antibiotic days from 2015 compared with 2017 (28.8 vs. 7.4 suspected episodes/1,000 ventilator-days, 5.5 vs. 0 confirmed episodes/1,000 ventilator-days and 211 vs. 34.7 antibiotic days/1,000 ventilation-days, respectively). Conclusion: The incidence of suspected VAP and concomitant antibiotic use is much higher than for confirmed VAP, therefore inclusion of suspected episodes should be considered for accurate evaluation. There is a high diagnostic inconsistency and a low reliability of interpretation of chest x-rays regarding VAP. Implementation of combined antimicrobial stewardship and infection control measures may lead to an effective decrease in VAP incidence and antibiotic use.

中文翻译：

---

新生儿呼吸机相关性肺炎：以抗菌素管理为重点的质量改进计划。

背景与目的：新生儿呼吸机相关性肺炎（VAP）是常见的医院感染，也是NICU中经验性抗生素治疗的常见原因。但是，关于诊断标准和管理尚无国际共识。第一步，我们通过文献综述分析了新生儿VAP的诊断标准，危险因素和治疗管理。第二步，我们旨在根据已发布的不同标准比较我们单位中的疑似和确诊新生儿VAP发作，并分析胸部X光片的间质可靠性。此外，我们旨在评估关于抗菌素管理和感染控制的多方面质量改进措施（VAP预防包，早期拔管政策，抗菌管理巡回赛）。方法：纳入2014年9月至2017年12月在卢塞恩州III级重症监护病房（ICU）住院的怀疑VAP妊娠直至44周的新生儿。根据4个诊断框架分析了VAP发作。评估了由10位高级医师完成的有关X线胸片解释的协议。计算并比较了2015年，2016年和2017年的可疑和确诊新生儿VAP发作和抗生素天数的年发生率。结果：在我们的文献综述中鉴定出17项研究。总体而言，大多数使用CDC准则或类似标准，将放射线照相术更改作为主要标准。比较怀疑的和确诊的新生儿VAP发作有很大差异（20.4 vs. 4.5 / 1,000呼吸机天）。X射线解释的间质可靠性差（类内相关系数0.25）。与2015年相比，已实施的更改导致年度VAP发生率和抗生素天数与2017年相比逐渐下降（28.8 vs.7.4疑似发作/ 1,000呼吸机天，5.5 vs.0确诊发作/ 1,000呼吸机天和211 vs.34.7抗生素天/ 1,000通风天数）。结论：可疑VAP和同时使用抗生素的发生率比确诊VAP高得多，因此应考虑纳入可疑事件以进行准确评估。诊断相关性很​​高，对VAP的胸部X光片解释的可靠性低。