# Multimodal Implementations to Reduce Neonatal Ventilator-Associated Pneumonia and Colistin Use: An Interrupted Time Series

## TL;DR

This study shows that a series of interventions over three time periods helped reduce neonatal ventilator-associated pneumonia and colistin use in a Thai neonatal intensive care unit.

## Contribution

The study demonstrates the effectiveness of a phased, multimodal approach in reducing neonatal VAP and antimicrobial use.

## Key findings

- The overall VAP incidence was 4.55 per 1000 ventilator days.
- Interventions in period 1 significantly reduced VAP and colistin use.
- Additive interventions in periods 2 and 3 sustained VAP reduction and limited colistin prescriptions.

## Abstract

Background/Objectives: We investigated multimodal strategies to reduce neonatal ventilator-associated pneumonia (VAP) and antimicrobial use across three periods: period 1 (2014–2017), environmental cleaning with sodium hypochlorite, installation of heat and moisture exchangers, elective high frequency oscillatory ventilation (HFOV) as the primary invasive mode, and nasal HFOV after extubation; period 2 (2018–2020), oral care with maternal milk; and period 3 (2021–2024), nasal synchronized intermittent positive pressure ventilation after extubation. Methods: We conducted a quasi-experimental study of all neonates admitted to a neonatal intensive care unit in Thailand. We compared the trends in VAP and antimicrobial use rates using interrupted time-series analysis with segmented regression. Results: During the 11-year study period, 45.6% of neonates were intubated (2470/5414), and the ventilator utilization ratio was 0.19 (17,820 ventilator days/95,151 patient days). The overall VAP incidence was 4.55 per 1000 ventilator days. The yearly VAP incidence density ratio was significantly lower than in 2014. The baseline trend of VAP incidence and colistin use decreased significantly during period 1; nonetheless, the level and slope did not differ significantly between periods 1, 2, and 3. Conclusions: Tailored implementations, namely environmental decontamination, ventilator circuit care, elective HFOV, and nasal HFOV, reduced VAP and colistin use during period 1. Moreover, additive interventions, including oral care in period 2 and nasal synchronized intermittent positive pressure ventilation in period 3, achieved sustained VAP reduction and limited colistin prescriptions in period 1.