Risk Factor Analysis and Outcomes of VAP in ICU Patients

at Arifin Achmad General Hospital in 2018:

Cohort Retrospective Study

Fachriani Putri

, Riza Iriani Nasution

1,2

Ridha Restilla

, Misyenni Rumaisya

Department of Public Health, Faculty of Medicine, University of Riau

Infection Prevention And Control Committee, Arifin Achmad General Hospital, Riau Province

*Corresponding author

Keywords: risk factors, outcome, Ventilator-associated pneumonia.

Abstract: Ventilator associated pneumonia (VAP) is a nosocomial pneumonia that occurs 48 hours or more after

mechanical ventilator usage through the endotracheal tube or the tracheostomy tube. VAP is one of the

nosocomial infections often found in the intensive care unit (ICU). The purpose of this study was to

determine the risk factors and outcomes of VAP. This study used a retrospective cohort design involving all

ICU patients at Arifin Achmad General Hospital in 2018 who met the inclusion criteria. The incidence of

VAP was 3.1% (95% CI 2.76 - 3.43). The onset of VAP that occurred within 5 days was 66.7%. A

significant factor was history of pulmonary disease (p = 0.04) with an RR of 8.2 (95% CI 1.7 - 40.1). There

was a significant correlation between the incidence of VAP and length of ICU stay (p = 0.002). The

incidence of VAP in Arifin Achmad General Hospital in 2018 was 3.1%. The onset of VAP incidence is

still within 5 days, so the prognosis is still good. Doctors and paramedics should pay more attention to ICU

patients who have a history of pulmonary disease.

1 INTRODUCTION

The incidence of pneumonia after mechanical

ventilation usage increases 3–10 times (Augustyn,

2007), and may causes nosocomial pneumonia if its

usage is more than 48 hours, either with

endotracheal tubes or after tracheostomy and is

called Ventilator-Associated Pneumonia (VAP)

(Hunter, 2005; Patricia , Dorrie, & Barbara, 2012)

Ventilator Associated Pneumonia (VAP) causes

an increase in morbidity and mortality of patients

that were treated in The Intensive Care Unit (ICU)

(Kahlil, 2017)

The incidence of VAP is quite high, varying

between 9-27% with a mortality rate of more than

50%. The incidence of VAP in Cipto

Mangunkusumo Hospital (RSCM) was 27.4% with a

mortality rate of 57.2% (Saragih, 2014). At

Pamukkale University Hospital, Denizli, Turkey for

38.1% with a mortality rate of 70.3% (Erbay, 2004).

VAP data on patients treated in the ICU and CVCU

rooms at Arifin Achmad General Hospital in Riau

Province was increasing from 3.3% in 2013 to

18.58% in 2015 (Nency, 2015).

There are two risk factors that may increase the

incidence of VAP, they were intervention factors

and patient factors. Intervention factors include

endotracheal intubation, duration of use of

mechanical ventilation, length of hospital stay, use

of Endotracheal Tube (ETT), catheters, central

venous pressure measurement, inappropriate use of

antibiotics, red blood cell transfusion, supine

position, and post-surgery.While the patient factors

include age over 60 years, gender, and Chronic

Obstructive Pulmonary Disease (COPD) (Gillepspie,

2009).

According to Saragih (2014), research on VAP in

Indonesia has not been comprehensive. Most of the

patients were lack of knowledge in VAP and do not

have health insurance, so they were admitted in

severe conditions. This resulted in more frequent

occurrences of VAP. VAP is one of the causes of

morbidity and mortality in ICU but also causes the

prolonging of the patient stay which may result in

the increasing cost of treatment (Wiryana, 20007).

Putri, F., Nasution, R., Restilla, R. and Rumaisya, M.

Risk Factor Analysis and Outcomes of VAP in ICU Patients at Ariﬁn Achmad General Hospital in 2018: Cohort Retrospective Study.

DOI: 10.5220/0009859400800086

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 80-86

ISBN: 978-989-758-469-5

This study was to determine the risk factors and

outcomes of VAP in ICU patients at Arifin Achmad

General Hospital during 2018.

2 METHODS

This study was an analytical study with a

retrospective cohort design. General and clinical

data during treatment were obtained from the

2019 at Arifin Achmad General Hospital in Riau

Province. The population in this study were all data

on patients using mechanical ventilators who were

admitted to the ICU in January-December 2018. The

samples in this study were all of the populations that

met the inclusion criteria using a total sampling

technique.

The inclusion criteria in this study were all

patients who used mechanical ventilators for more

than 48 hours in the ICU and had complete data

(age, sex, postoperative procedure, history of

pulmonary disease (COPD, Lung Ca, asthma,

Pneumonia, Pulmonary TB), onset VAP, outcome of

VAP (death or life), and length of stay.

Data obtained from register books are processed

using computer statistics programs. Univariate

analysis was carried out descriptively by using

frequency distribution tables and calculating

percentages. While the bivariate analysis was carried

out using the chi-square statistical test and the

mean/median difference test. Occurrence risk is

measured using the value of Relative Risk (RR).

The permission of this research was

obtainedfrom the Medical and Health Research

Ethics Unit of the University of Riau Medical

School No. 061 / UN.19.5.1.1.8 / UEPKK / 2019.

3 RESULTS

During the period January-December 2018, there

were 456 ICU patients who were treated more than 2

days (48 hours). 259 of them used mechanical

ventilators, but only 192 patients met the inclusion

criteria. Demographic and clinical characteristics of

the research subjects can be seen in table 1.

Table 1. Demographic and clinical characteristics of Arifin

Achmad Hospital ICU patients in 2018.

Variable Total Percentage

(%)

Age

≥ 60 years 48 25

< 60 years 144 75

Gender

Man 97 50,5

Woman 95 49,5

Post surgery

Yes 139 72,4

Not 53 27,6

Pulmonary disease history

Yes 11 5,7

Not 181 94,3

In this study, the average age of ICU patients was

52.5 years (19-85) years. Most were found at <60

years of age (75%). The result of this study is the

same as the result of Nency's (2015) study at Arifin

Achmad General Hospital and Salukanan (2017) at

RSUP dr. Hasan Sadikin Bandung, each of whom

found 76.2% and 77.1% of ICU patients aged <60

years.

ICU patients were found slightly more in men

(50.5%) than women (49.5%). The resultof this

study is the same as those of Saragih (2014) at

RSCM, and Susmiarti (2015) in Rumkital, dr.

Ramelan Surabaya, each of which found 53.7%, and

83.3% of ICU patients were male.

139 ICU patients were found after surgery

(72.4%). Similarly, the result of the Ciginskiene

study (2019) at Lithuanian University of Health

Sciences found 38.3% after surgical intervention.

And Turkovic's (2017) research result at the

University Hospital Center in Zagreb, Croatia which

found 72% of ICU patients before tracheotomy and

82% after tracheotomy after neurosurgical. The

resultof the Salukanan study (2017) also found that

40% of ICU patients after post laparotomy for

various reasons, 26.4% after post craniotomy for

various reasons.

In this study, patients who did not have a history

of lung disease were more than those who had a

history of pulmonary disease,181 patients (94.3%).

Similarly, Susanti's (2015) research result at Eka

Hospital Pekanbaru and Abbasinia (2016) in Al-

Zahra Hospital, Isfahan, Iran, each of which found

70% and 46.9% of ICU patients had no history of

pulmonary disease.

Risk Factor Analysis and Outcomes of VAP in ICU Patients at Ariﬁn Achmad General Hospital in 2018: Cohort Retrospective Study

Table 2. The incidence of Ventilator-associated

pneumonia in ICU Arifin Achmad Hospital patients in

2018.

Category N %

VAP 6 3,1

Not VAP 186 96,9

Total 192 100

From table 2, it was found that of 192 patients

admitted to the ICU, there were 6 patients suffered

from VAP (3.1%). Similarly, Saragih's research

result: 27.4%; Nency: 18.58%; Salukanan: 8.5% and

Turkovic: 42%.

Table 3. Onset of The Incidence of Ventilator-Associated

Pneumonia in ICU Patients at Arifin Achmad Hospital in

2018.

Ventilator associated pneumonia N %

 ≤ 5 days

4 66,6

 >5 days

2 33,4

Total 6 100

From table 3, it is known from 6 patients suffered

from VAP, 4 patients experienced it in ≤ 5 days

(66.6%). Similarly, the result of Nency's research:

95.2%; Saragih: 52.2%; Abbasinia (2016) in the ICU

of Al-Zahra Hospital, Isfahan, Iran: 18.8% and

Agustina (2018) in the RSUD Dr. Loekmono Kudus

Hadi: 46.7%.

Table 4. Outputs for Arifin Achmad Hospital ICU patients

in 2018.

Outcome N %

 Died

66 34,4

 Life

126 65,6

Total 192 100

Length of ICU stay (days) (med,min-max)

 VAP

12,5 (7 – 36)

 Not VAP

4 (2 – 52)

From table 4, it is known that from 192 patients

admitted to the ICU, more patients lived than died.

(65.6% vs 34.4%). The result of this study is the

same as those of Turkovic (2017) who found that

more patients lived than died. 65% before

tracheotomy and 75% after tracheotomy. However,

it is different from the result of Erbay (2004) in

Pamukkale University Hospital, Denizli, Turkey,

Saragih (2014) and Salukanan (2017), which found

more patients died than living. Each of them was

70.3%, 57.2%, 60%.

The average length of ICU stay for VAP patients

in this study was 12.5 (7-36) days. Similarly, the

research result of Dewi (2014) at Dr. RSUP Kariadi

Semarang found an average of 12.21 ± 9.578 days

and Erbay (2004) 8 days.

Table 5. Bivariate Analysis of VAP Risk Factors.

VAP Not

VAP

value

N % n %

Age

≥ 60

years

1 16

47 25

1 0,6

< 60

years

5 83

139 74

(0,0

72-

Genders

Man 3 50 94 50

1 0,97

Woman 3 50 92 49

(0,2

03-

4,73

)

Post

surgery

Yes 4 66

135 72

0,669 0,76

Not 2 33

51 27

(0,1

44-

4,04

)

Pulmon

ary

disease

history

Yes 2 33

9 4,

0,04* 8,2

Not 4 66

177 95

(1,6

40,1

)

* Pulmonary disease history: COPD, Lung Ca, asthma,

Pneumonia, Pulmonary TB

Table 5 shows that pulmonary disease history is the

only variable that has a significant difference in the

incidence of VAP (p = 0.04). This is similar to the

result of Saragih (2014) and Ibrahim (2000) at

Barnes Jewish Hospital in St. Louis, MO, who found

significant differences in patients with

comorbidities, one of which was Chronic

Obstructive Pulmonary Disease. While other

variables such as age, gender and postoperative

procedures did not show a significant difference

with the incidence of VAP.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

Table 6. VAP Outcome Bivariate Analysis.

Died Life p value RR

N %

n % 95% CI

VAP

Yes 3 50 3 50 0,415 1,47

Not 63 33,9 123 66,1 66,1

0,64 –

3,36

Table 6 shows that the proportion of VAP patients

who died and lived was equal to 50% but did not

show a significant difference. Similarly, the results

of a study by Kahlil (2017) which found no

significant difference (p = 0.662) in group I (60%)

and group II (70%) deaths that shared a positive

culture after 48 h of mechanical ventilatio.

Table 7. Differences in duration of care for ICU patients

who experience VAP and not VAP.

VAP Not VAP p value

Length of

ICU stay

(days)

(med,min

-max)

12,5

(7 – 36)

(2 – 52)

0,002*

Table 7 shows that the incidence of VAP showed a

significant difference with the length of ICU stay of

patients in the ICU (12.5 days). The results of the

Turkovic (2017) study also found a significant

difference in the length of stay of VAP patients

before and after the tracheotomy, which was 5 (4-9)

days to 11 (10-13) days with p = 0.001. Similarly,

the Rello (2002) study found a greater number of

ICU days (11.7 ± 11.0 days, p <0.001) and longer

hospital length of stay (25.5 ± 22.8 days, p <0.001).

4 DISCUSSION

4.1 Age

In this study, the average age of ICU patients was

52.5 years (19-85) years. Most were found at <60

years of age (75%). The incidence of VAP was also

more common at <60 years of age (83.3%) but was

not significantly associated.

According to Smeltzer and Bare (2013) age is

one of the factors that may affect a person's immune

system which will affect someone’s ability to react

to microorganisms. In addition, an increase in age

will also reduce the production and function of T

and B lymphocytes and thus increase the incidence

of autoimmune diseases. Therefore, the frequency

and intensity of infections will increase in old age. It

can be said that age <60 years or 60 years is equally

at risk of VAP.

4.2 Gender

In this study, the comparison of male and female

patients in ICU are similar (50.5% vs. 49.5%). The

incidence of VAP was also similar in male and

female patients (50% vs 50%) and was not

significantly associated.

Pneumonia infection is more common in men

than women because of the estrogen in women

which can activate nitric oxide synthase-3 (NOS3)

that can increase the activity of macrophages to kill

infectious microbes (Lee, 2008 & Yang et al, 2014)

But according to Sukmadi (2018), patients

admitted to the ICU are not always dominated by

one sex either male or female.

4.3 Post Surgery

In this study, most ICU patients were patients who

were treated after surgery (72.4%). VAP events were

also more common in patients after surgery (66.7%)

but were not significantly associated.

The results of the Cunnion study (1996) found

more incidence of VAP in postoperative patients

than non-surgical patients. Especially in patients

after cardiothoracic surgery and head injury. This is

due to low preoperative albumin levels, prolonged

preoperative care and difficult surgical procedures.

According to Mc Carthy et al (2008) the

installation of the endotracheal tube (ETT) and

decreased consciousness due to anesthesia after

surgery will reduce the patient's ability to swallow

effectively and eliminate coughing which is the

body's natural defense mechanism against

respiratory tract infections. As a result, when

microorganisms enter the lungs, the body's defense

mechanism cannot kill the organism. In addition,

esophageal reflux and aspiration of gastric contents

in ETT patients can also cause endobronchial

colonization and pneumonia.

4.4 Pulmonary Disease History

In this study, 94.3% of ICU patients had not a

history of pulmonary disease (COPD, Lung Ca,

asthma, Pneumonia, Pulmonary TB). 33.3%

developed into VAP but were significantly

associated (p value = 0.04).

Risk Factor Analysis and Outcomes of VAP in ICU Patients at Ariﬁn Achmad General Hospital in 2018: Cohort Retrospective Study

Susanti's (2015) study found 30% of patients

with pulmonary disease: COPD, respiratory failure

and Acute Long Oedema (ALO) using a ventilator.

When using a ventilator, the risk of being treated

will be longer compared to patients who do not use a

ventilator, and will increase the risk of suffering

from VAP.

According to Price (2006), one lung disease that

can cause pneumonia is COPD. Patients with COPD

experience epithelial and ciliary damage in their

respiratory tract. Because it is damaged, the

production of goblet cells will increase. Goblet cells

produce sputum which becomes a place for microbes

to develop. This explains why pneumonia infection

often occurs in acutely exacerbated COPD patients

(Sogaard et al, 2016).

Pneumonia in COPD patients will increase

pulmonary function disorders, increase hypoxemia

and infection, resulting in systemic inflammation,

sepsis to organ failure (Sogaard et al, 2016).

Bronchitis and pneumonia are the most common

hospital infections in ICUs Kahlil (2017).

4.5 VAP Incidence

The incidence of VAP in this study was only 3.1%.

According to Agustyn (2007) the incidence of VAP

in patients using mechanical ventilation was 22.8%

and contributed to 86% of nosocomial infections.

Whereas according to Turkovic (2017) the incidence

of VAP in ICU which is reported as 15.5% and

9.3%. Chen et al's research in Taiwan found a VAP

incidence of 3.18 per 1000 days of ventilator use and

ranked second in the ICU.

The results of the Salukanan study (2017) found

an incidence of VAP of 8.5 cases per 1,000 days of

ventilator use. This figure is quite high, but it is still

within tolerance in developing countries. Because

the incidence of VAP in developing countries range

from 1.2 to 8.5 per 1,000 days of ventilator use.

Compare this with developed countries ranging from

0.2 to 4.4 per 1,000 days of ventilator use.

According to Amanullah and Posner (2010),

28% of complications of the patients who use

mechanical ventilation cause VAP. The incidence is

directly proportional to the duration of use of

mechanical ventilation. Estimated incidence of 3%

per day for the first 5 days, 2% per day for 6-10

days, and 1% per day after 10 days.

4.6 VAP Onset

The onset of VAP≤ 5 days in this study was 66.6%.

According to Ibrahim (2000), in general, early onset

VAP (≤ 5 days) has a better prognosis because

germs are still sensitive to antibiotics. Conversely,

late-onset VAP (> 5 days) has a worse prognosis

because there has been colonization of Multi-Drug

Resistant (MDR) bacteria so that the mortality rate

will increase (Torres, 2004 & Nency, 2015)

4.7 Outcome

4.7.1 Died/Life

The number of ICU patients who died in this study

was less than those living (34.4% vs. 65.6%).

However, the number of VAP patients who died and

lived was equal (50% vs. 50%), although it was not

significantly related.

Some studies have found a relationship between

death and VAP. These include the Turkovic (2017)

case-control study in 85 VAP patients and 85 non

VAP patients at the University Hospital Center in

Zagreb, Croatia. He found 40% of deaths in VAP

patients and 38.8% in non VAP patients. There were

no significant differences between the two

classifications.

The Fagon et al. Study, in 1.118 patients using

mechanical ventilation, found an association

between VAP and a one-and-a-half increase in the

risk of death (odds ratio, 1.51; 95% CI, 1.11-2.03)

(Safdar, 2005) .

According to Erbay (2004) the main cause of

death from hospital-acquired infections is

Nosocomial Pneumonia (NP). 25% of nosocomial

infections in hospitals are distributed by patients

admitted to the ICU. The cause of high nosocomial

infections in the ICU is due to the patient’s main

diagnosis, the severity of the disease, the length of

treatment and the invasive device used by the

patient. The estimated prevalence of NP within the

hospital settings ranges from 10% to 65%, with case

fatality rates which is greater than 25% in most

studies.

According to Saragih (2014) the high mortality

rate of VAP in Indonesia besides due to improper

use of antibiotics, also caused by the management is

not optimal, which is caused by limited funds (66%

of the research subjects have no health insurance).

4.7.2 Length of ICU Stay (days)

The average length of stay for VAP patients in this

study was 12.5 (7-36) days. 3 times longer than the

treatment of patients who were not diagnosed with

VAP. The results of the analysis showed a

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

significant difference between the length of stay

with the incidence of VAP (p-value: 0.002).

The results of the study by Kahlil (2017) found

that the length of stay in the ICU was around 7-54

days. According to the study, VAP is an infection in

a hospital that has an impact on the length of stay,

increased hospital costs and a greater risk of death.

Turkovic (2017) also found that VAP patients

were treated longer in the ICU than patients without

VAP. Several studies report that patients with VAP

have increased the length of stay and hospital costs

(Safdar, 2005). Warren et al. (2003) reported that the

cost of hospitalization for patients with VAP was

significantly higher than for patients without VAP ($

70,568 vs. $ 21,620). Rello (2002) found the average

hospital bill for VAP patients to be $ 104,983 ± $

91,080. Which is significantly bigger.

In addition Rello (2002) also found that patients

with VAP had a significantly longer hospital length

of stay (25.5 ± 22.8 days, p <0.001) and a greater

number of ICU days (11.7 ± 11.0 days, p <0.001).

The number of days of treatment for patients with

VAP is longer than for patients without VAP. 9.6

days longer due to mechanical ventilation, 6.1 days

longer in the ICU, and 11.5 days longer in the

hospital. And the average hospital bill cost of VAP

patients is $ 40,000, which is significantly higher

than patients without VAP.

5 CONCLUSION

VAP study was as much as 3.1%. The onset of VAP

found within 5 days 66.6%, it is expected that the

prognosis will be better. This study showed that risk

factors for pulmonary disease history were only

33.3% but were significantly associated with the

incidence of VAP (p-value = 0.04, RR = 8.2 (1.6-

40.1)). VAP occurrencewere significantly related

with length of stay for patients in the ICU (p-value =

0.002), with a median of 12.5 (7-36) days.

From this study we concluded that VAP needs

more attention to prevent its occurrence. As once

diagnosed, it usually increases ICUs mortality rates

and its potentially substantial attributable moretality

rates.

ACKNOWLEDGMENTS

Appreciation goes to Arifin Achmad General

Hospital and staff of the ICU and infection

prevention and control committee who helped us in

conducting this study.

REFERENCES

Abbasinia M, Bahrami N, Bakhtiari S, Yazdannik A,

Babaii A. 2016. The Effect of a Designed Respiratory

Care Program on the Incidence of Ventilator-

Associated Pneumonia: A Clinical Trial. Journal of

Caring Sciences, 5(2) : 161-167.

Augustyn, B. 2007. Ventilator-associated pneumonia risk

factors and prevention. Critical Care Nurse, 27(4) : 32-

39.

Ciginskien A, Dambrauskien A, Rello J and Adukauskien

D. 2019. Ventilator-Associated Pneumonia due to

Drug-Resistant Acinetobacter baumannii: Risk Factors

and Mortality Relation with Resistance Proﬁles, and

Independent Predictors of In-Hospital Mortality.

Medicina, 55, 49 : 1-13.

Dewi H, Harahap MS. 2014. Hubungan Usia Penderita

Ventilator Associated Pneumonia Dengan Lama

Rawat Inap Di ICU RSUP Dr. Kariadi Semarang.

Jurnal Media Medika Muda : 1-14.

Erbay RH, Yalcin AN, Zencir M, Serin S, Atalay H. 2004.

Costs and risk factors for ventilator-associated

pneumonia in a Turkish University Hospital's

Intensive Care Unit: A case-control study. BMC

Pulmonary Medicine 4 : 1-7.

Gillespie, R., 2009. Prevention and Management of

Ventilator-Associated Pneumonia – The Care Bundle

Approach, (Online), available from

(http://ajol.info/index.php., 15th march 2019).

Ibrahim EH, Ward S, Sherman G, Kollef MH. 2000. A

comparative anlysis of patients with early-oset vs late-

onset nosocomial pneumonia in the ICU setting. Chest

117 : 1434-42.

Kahlil, NH , Khalil AT , Abdelaal DE. 2017. Comparison

study between bacteriological aetiology and outcome

of VAT & VAP. Egyptian Journal of chest Diseases

and Tuberculosis 66 : 169-174.

Hunter JD. 2006. Ventilator associated pneumonia.

Postgrad Med J 82 (965) : 172-8.

McCarthy, S.O, et al., 2008. Ventilator Associated

Pneumonia Bundled Strategies; An Evidence-Based

Practice. Worldview on Evidence-Based Nursing

fourth quarter : 193–204.

Nency C, Irawan D, Andrini F. 2015. Gambaran Kejadian

Ventilator-Associated Pneumonia Pada Pasien Yang

Dirawat Di ICU Dan CVCU RSUD Arifin Achmad

Periode Januari 2013 S/D Agustus 2014. JOM FK

Volume 2 No. 2 Oktober 2015 : 1-9.

Patricia, G., Dorrie, F., & Barbara, M. 2012. Keperawatan

kritis pendekatan asuhan holistik: Jakarta: EGC.

Price, A. 2006. Patofisiologi konsep kilinis proses-proses

penyakit. Jakarta: EGC.

Rello J, et al. 2002. VAP Outcomes Scientific Advisory

Group. Epidemiology and outcomes of ventilator-

Risk Factor Analysis and Outcomes of VAP in ICU Patients at Ariﬁn Achmad General Hospital in 2018: Cohort Retrospective Study

associated pneumonia in a large US database. Chest

122 : 2115-2121.

Safdar N, Dezfulian C, Collard HR, Saint S. 2005. Clinical

And Economic Consequences Of Ventilator-

Associated Pneumonia: A Systematic Review. Crit

Care Med 2005 Vol. 33, No. 10 : 2184-2193.

Saragih RJ, Amin Z, Soedono R, Pitoyo CW, Rumende

CM. 2014. Prediktor mortalitas pasien dengan

ventilator-associated pneumonia di RS Cipto

Mengunkusumo. Departemen Anestesiologi dan

Perawatan Intensif FK UI: Vol.2 No.2.

Salukanan RT, Zulfariansyah A, Sitanggang RH. 2018.

Pola Pneumonia Nosokomial di Unit Perawatan

Intensif Rumah Sakit Umum Pusat Dr. Hasan Sadikin

Bandung Periode Januari–Desember 2017. JAP,

Volume 6 Nomor 2, Agustus 2018 : 126-136.

Smeltzer, Bare SC, Brenda. G, 2013. Buku Ajar

Keperawatan Medikal Bedah Brunner & Suddarth.

Ed.8. Vol. 3. Jakarta: EGC :1698 – 1700.

Sukmadi A, Pujiastuti SE, Santjaka A, Supriyadi. 2018.

Effectiveness Of Suction Above Cuff Endotracheal

Tube In Preventing Ventilator Associated Pneumonia

In Critical Patients In Intensive Care Unit. Belitung

Nursing Journal. 2018 August; 4 (4) : 380-389.

Susmiarti D, Harmayetty, Dewi YS. 2015. Intervensi Vap

Bundle Dalam Pencegahan Ventilator Associated

Pneumonia (Vap) Pada Pasien Dengan Ventilasi

Mekanis (The Incidence of VAP after VAP Bundle

Intervention Among Patients with Mechanical

Ventilation). Jurnal Ners Vol. 10 No. 1 April 2015 :

138–146.

Susanti E , Utomo W , Dewi YI. 2004. Identifikasi Faktor

Resiko Kejadian Infeksi Nosokomial Pneumonia Pada

Pasien Yang Terpasang Ventilator Di Ruang Intensive

Care. JOM Vol 2 No 1, Februari 2015 590 : 590-599.

Torres A, Ewig S. 2004. Diagnosing ventilator associated

pneumonia. N Engl J Med 2004. 350 : 433-522.

Turković TM, Obraz M, Glogoški MZ, Juranić I, Bodulica

B, Kovačić J. 2017. Incidence, Etiology And Outcome

Of Ventilator-Associated Pneumonia In Patients With

Percutaneous Tracheotomy. Acta Clin Croat, Vol. 56,

No.1, 2017: 99-109.

Warren DK, Shukla SJ, Olsen MA, Kollef MH,

Hollenbeak CS, Cox MJ, Cohen MM, Fraser VJ. 2003.

Outcome and attributable cost of ventilator-associated

pneumonia among intensive care unit patients in a

suburban medical center. Crit Care Med 2003,

31:1312-1317.

Wiryana, M. 2007. Ventilator Associated Pneumonia. J

Peny Dalam, Volume 8 Nomor 3 Bulan September;

2007 : 254-268.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease