Westyn Branch-Elliman, Sharon B. Wright, and Michael D. Howell  Am. J. Resp. Crit. Care Med. Jul 1, 2015, vol. 192, no. 1: 57-63

Rationale: Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection with high associated cost and poor patient outcomes. Many strategies for VAP reduction have been evaluated. However, the combination of strategies with the optimal cost–benefit ratio remains unknown.

Objectives: To determine the preferred VAP prevention strategy, both from the hospital and societal perspectives.

Methods: A cost–benefit decision model with a Markov model was constructed. Baseline probability of VAP, death, reintubation, and discharge from the intensive care unit (ICU) alive were ascertained from clinical trial data. Model inputs were obtained from the medical literature and the U.S. Department of Labor; a device cost was obtained from the manufacturer. Sensitivity analyses were completed to test the robustness of model results.

Measurements and Main Results: Overall least expensive strategy and the strategy with the best cost–benefit ratio, up to a willingness to pay threshold of $50,000–100,000 per case of VAP averted was sought. We examined a total of 120 unique combinations of VAP prevention strategies. The preferred strategy from the hospital perspective included subglottic suction endotracheal tubes, probiotics, and the Institute for Healthcare Improvement VAP Prevention Bundle. The preferred strategy from the point of view of society also included additional prevention measures (oral care with chlorhexidine and selective oral decontamination). No preferred strategies included silver endotracheal tubes or selective gut decontamination.

Conclusions: Despite their infrequent use, current data suggest that the use of prophylactic probiotics and subglottic endotracheal tubes are cost-effective for preventing VAP from the societal and hospital perspectives.

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