Ventilator-Associated Pneumonia in Low- and Middle-Income vs High-Income Countries: The Role of Ventilator Bundle, Ventilation Practices, and Health Care Staffing.

Summary

In a 2,253-patient international cohort, LMIC status independently doubled VAP risk. Longer ventilation increased VAP, and higher nurse and physician staffing ratios reduced VAP, while ventilator bundle adherence showed no independent association after adjustment.

Key Findings

• LMIC status independently associated with higher VAP risk (aOR 2.11; 95% CI 1.37–3.24).
• Each increase in total ventilation duration increased VAP risk (aOR 1.04; 95% CI 1.03–1.05).
• Higher nurse (aOR 0.88; 95% CI 0.79–0.98) and physician staffing (aOR 0.69; 95% CI 0.50–0.87) ratios associated with lower VAP; bundle adherence showed no independent association.

Clinical Implications

Prioritize minimizing ventilation duration and improving nurse/physician staffing ratios to reduce VAP; bundle elements remain important but may be insufficient without adequate staffing and systems.

Limitations

• Observational secondary analysis—causality cannot be inferred; potential unmeasured confounders (infrastructure, infection control).
• Heterogeneity in VAP definitions and bundle implementation across sites may influence associations.

Future Directions

Prospective interventional studies to test staffing enhancements and ventilation weaning strategies on VAP; context-specific implementation science in LMIC ICUs.