ICU care bundles and infection prevention

Ventilator-associated pneumonia prevention bundle

Reviewed Nov 2026·4 references
New· views rounded down, updated weekly

Essential VAP/VAE prevention practices from SHEA 2022: avoid intubation, minimise sedation, SAT/SBT, mobility, head-up, subglottic drainage and oral care.

Definition
VAP: pneumonia developing > 48 h after intubation. SHEA 2022 classifies prevention practices as essential (good evidence, low risk) and additional; the focus has shifted to reducing ventilator days and ventilator-associated events (VAE).

At the bedside

  1. 1

    Avoid intubation

    Use HFNC or NIV where appropriate to prevent intubation.

  2. 2

    Minimise sedation

    Avoid benzodiazepines; target light sedation; daily spontaneous awakening trials.

  3. 3

    Daily SBT

    Daily

    Paired with SAT, to extubate at the earliest opportunity.

  4. 4

    Early mobility

    Progressive rehabilitation as tolerated.

  5. 5

    Subglottic drainage

    Use endotracheal tubes with subglottic secretion drainage for patients expected to need ventilation > 48-72 h.

  6. 6

    Head of bed

    Elevate 30-45°.

  7. 7

    Oral care

    BD

    Toothbrushing (without chlorhexidine) at least twice daily.

  8. 8

    Circuit care

    Change ventilator circuits only if visibly soiled or malfunctioning; keep cuff pressure 20-30 cmH₂O.

SHEA 2022 VAP prevention (adults)

CategoryPractice
EssentialAvoid intubation (HFNC/NIV); minimise sedation; SAT + SBT daily; early mobility; subglottic drainage tubes if > 48-72 h; head-of-bed 30-45°; change circuits only when soiled
AdditionalSelective oral or digestive decontamination (in settings with low antimicrobial resistance); daily toothbrushing
Generally not recommendedChlorhexidine oral care; probiotics; silver-coated tubes; routine stress ulcer prophylaxis for VAP prevention; early tracheostomy for VAP prevention

Summary of SHEA/IDSA/APIC 2022 recommendations; see source for full grading.

Red flag · call your senior now
New fever, purulent secretions, rising FiO₂/PEEP after ≥ 2 days of stable ventilation: suspect VAP or other VAE - culture and assess (see icu-infections module).
Pitfall
Chlorhexidine 0.12% oral rinse as routine VAP prevention - not recommended, possible harm.
Pitfall
Leaving the bed flat during transfers, imaging and procedures.
Pearl
The strongest VAP prevention is a shorter ventilation episode: every bundle element that shortens ventilation counts.

References

  1. 1

    Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol 2022;43:687-713.

  2. 2

    Devlin JW, Skrobik Y, Gelinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Crit Care Med 2018;46:e825-73.

  3. 3

    Farkas J. The Internet Book of Critical Care (IBCC). EMCrit Project; continuously updated.

  4. 4

    National Centre for Disease Control, DGHS, MoHFW. National guidelines for infection prevention and control in healthcare facilities. New Delhi: Government of India; January 2020.

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