Low adherence to VAP prevention bundles in LMIC ICUs: gaps and barriers

Background

Ventilator-associated pneumonia (VAP) is a major healthcare-associated infection (HAI) in intensive care units (ICUs), with a high burden in low- and middle-income countries (LMICs). Despite WHO-recommended prevention bundles, adherence remains low, leading to preventable infections and antimicrobial resistance (AMR). This review maps existing evidence on VAP prevention practices and bundle adherence in LMIC ICUs.

Methods

A scoping review (Arksey & O’Malley; PRISMA-ScR) was conducted using PubMed, Scopus and Web of Science (2010–2026). Observational ICU studies from LMICs on VAP prevention and adherence were included. Two-stage screening was conducted (title/full-text). A total of 293 records were identified; 285 remained after duplicate removal, 38 full-text articles were assessed for eligibility, and 21 studies analysed. Data were synthesised descriptively.

Results

Studies covered LMICs across Asia, the Middle East, Latin America, and Africa. Adherence was low; full bundle compliance rarely exceeded 2%. Head-of-bed elevation (30°–45°) showed high adherence (up to 97%), while key practices such as sedation interruption, extubation assessment remained suboptimal (<60%). Subglottic suctioning showed inconsistent implementation (11–47%) and was absent in some settings. Hand hygiene ranged from 57 to 78%, while oral care was 9.4%. Only 44.2% of ICU staff adhered to basic measures, despite 83.4% reporting protocol use. Up to 94% of nurses reported staffing shortages, and 75% reported limited resources as barriers to adherence. Evidence was geographically uneven, with limited data from several LMIC regions.

Conclusions

VAP burden in LMIC ICUs appears driven more by implementation gaps than knowledge deficits. Improving low-adherence practices through routine monitoring and feedback, while addressing staffing and resource constraints is essential for full bundle adherence. More research in underrepresented LMICs is needed to guide effective interventions.

Key messages

• Low adherence to VAP prevention bundles in LMIC ICUs reflects systemic gaps in staffing, resources, and infection prevention systems rather than knowledge deficits alone.

• Reducing VAP in LMIC ICUs requires strengthening infection prevention systems by targeting low-adherence practices through monitoring and feedback, with adequate staffing and essential supplies.