The prevalence of Ventilator-Associated Pneumonia (VAP) and its associated factors among mechanically ventilated patients in Ethiopia. A systematic review and meta-analysis

The prevalence of Ventilator-Associated Pneumonia (VAP) and its associated factors among mechanically ventilated patients in Ethiopia. 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A systematic review and meta-analysis Mengistu Abebe Messelu, Getachew Tilaye Mihiret, Geremew Bishaw Mekonen, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7950644/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Ventilator-associated pneumonia (VAP) is a common nosocomial infection that occurs in critically ill patients who are on mechanical ventilation. Despite the growing number of individual studies, there is a lack of comprehensive synthesis of evidence on the prevalence and associated factors of ventilator-associated pneumonia in Ethiopia. Insight into these patterns is crucial to informing effective infection prevention strategies, optimizing patient outcomes, and guiding evidence-based clinical practice and resource allocation. Therefore, this study aimed to assess the prevalence and associated factors of ventilator-associated pneumonia in Ethiopia. Methods: This systematic review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A structured search of databases (PubMed, Google Scholar, CINAHL, Scopus, HINARI, African Journal of Online (AJOL), and Web of Science) was undertaken. The quality of the included studies was independently evaluated by two reviewers using validated critical appraisal instruments. A meta-analysis using a random-effects model was conducted to estimate the pooled prevalence. Heterogeneity among studies was assessed using the I² statistic. To identify the potential sources of heterogeneity, subgroup analyses and meta-regression were performed. Publication bias was evaluated using Egger’s test and visual inspection of funnel plots. All statistical analyses were conducted using STATA version 17.0. Results: A total of seven studies comprising 2,106 participants were included in the analysis. The pooled prevalence of ventilator-associated pneumonia among mechanically ventilated patients in Ethiopia was 24.79% (95% CI: 16.60, 32.97), as estimated using a random-effects model. Regional subgroup analysis revealed that the highest prevalence of VAP was observed in Addis Ababa (29.06%; 95% CI: 16.81, 41.31), followed by the Amhara region (24.79%; 95% CI: 16.60, 32.97). Subgroup analysis by age group indicated that the prevalence of VAP was higher among adult patients (26.90%; 95% CI: 15.68, 38.12) compared with pediatric patients (24.79%; 95% CI: 16.60, 32.97). Being male increased the odds of developing VAP by 76% compared to females (OR: 1.76, 95% CI: 1.24, 3.36), patients who undergoing tracheostomy were 6.5 times higher odds of developing VAP compared to their counterparts (OR: 6.47, 95% CI: 3.71, 11.27), and patients who ventilated more than 7 days had 5.2 times higher odds of developing VAP compared to those who ventilated fewer than 7 days (OR: 5.18, 95% CI: 2.84, 9.46). Conclusion and recommendations: Nearly one in four mechanically ventilated patients in Ethiopia develop VAP during intensive care unit admission. The risk is particularly high among males, patients undergoing tracheostomy, and those requiring prolonged mechanical ventilation. These findings underscore the substantial burden of VAP and its impact on patient outcomes in Ethiopian intensive care units. Therefore, special attention should be given to males, patients undergoing tracheostomy, and those on prolonged mechanical ventilation. In addition, strengthening infection control measures and improve the implementation of VAP prevention bundles are critical to mitigating the burden of VAP and improving patient outcomes. Ventilator-associated pneumonia VAP Prevalence Meta-analysis Ethiopia Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection that occurs in patients receiving mechanical ventilation for at least 48 hours ( 1 ). It is one of the most common and serious nosocomial infections among patients receiving mechanical ventilation in Intensive Care Units (ICUs) ( 1 , 2 ). It associated with increased morbidity, longer hospitalizations, higher healthcare costs, and increased mortality rates worldwide ( 3 – 5 ). In low- and middle-income countries, including Ethiopia, the burden of VAP is often underestimated due to limited surveillance, diagnostic challenges, and variable infection control practices ( 5 , 6 ). Previous studies in Ethiopia have reported varying prevalence rates and identified several risk factors, including age, sex, duration of ventilation, poor oral hygiene, underlying comorbidities, re-intubation, tracheostomy care, and the use of broad-spectrum antibiotics ( 6 – 11 ). Despite several individual studies reporting the prevalence and risk factors of VAP in different regions of Ethiopia, the findings are inconsistent, with substantial variation in reported prevalence rates. Additionally, the specific factors that increase the risk of VAP have not been systematically synthesized. This lack of comprehensive evidence hinders the development of standardized prevention protocols and targeted interventions, leaving patients vulnerable to preventable complications. Understanding these the prevalence and its determinants is crucial for guiding effective infection prevention strategies, improving patient outcomes, and guiding healthcare policy and resource allocation. Therefore, this systematic review and meta-analysis aims to estimate the pooled prevalence of VAP and identify its associated factors among mechanically ventilated patients in Ethiopia. Methods Study registration and reporting protocol This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure transparency and standardized reporting. Searching strategy Following the PRISMA guidelines, a comprehensive literature search was conducted in PubMed, Web of Science, Scopus, CINAHL, EMBASE, HINARI, and Google Scholar without restriction on publication year. To capture unpublished studies and grey literature, Google Scholar was also searched up to September 30, 2025. All retrieved studies, both published and grey literature, were critically evaluated for eligibility. The search strategy employed a combination of Medical Subject Headings (MeSH) terms and keywords related to “ventilator-associated pneumonia,” “VAP,” “mechanical ventilation,” and “Ethiopia.” Reference lists of eligible articles were manually screened to identify additional relevant studies. The CoCoPoP framework was used to structure the search terms as follows: ( Condition : “ventilator-associated pneumonia,” “VAP,” “nosocomial pneumonia,” “hospital-acquired pneumonia;” Context : “Ethiopia,” “Ethiopian hospitals,” “intensive care unit,” “ICU,” and “critical care;” Population : mechanically ventilated patients,” “intubated patients,” and “ventilated patients”). Boolean operators (“AND” and/or “OR”) were applied to combine search terms and optimize retrieval of relevant studies. Eligibility criteria This review included observational studies, prospective and retrospective cohort, cross-sectional, and case-control designs, that reported the prevalence of VAP and its associated factors among mechanically ventilated patients in Ethiopia. Articles that did not provide a full access, case reports, and letters were excluded. Outcomes The primary outcome of this review was the prevalence of VAP in Ethiopia, reported as both a percentage and a frequency in the included studies. The secondary outcome was the identification of factors associated with VAP. To enhance the validity of the analysis, only factors reported in at least two studies were included in the pooled analysis. Data extraction and data quality assessment The articles identified through the literature search were initially screened by title and abstract for eligibility in the systematic review by independent reviewers (M.A.M., T.A.B., and B.T.A.). Studies that met the inclusion criteria during this initial screening were subjected to full-text review. The full texts of eligible studies were independently assessed by a separate group of reviewers (G.T.M., K.S.W., G.B.M., M.M.T., A.G., H.A.A., and M.G.) to determine their inclusion in the final analysis. Any disagreements were resolved by referring to the predefined inclusion and exclusion criteria, with a third reviewer (M.L.) making the final decision when necessary. Data extraction was performed using Microsoft Excel 2019, capturing information on the author, publication year, study region, prevalence of VAP, sample size, study design, and population group. Two independent reviewers (M.A.M. and T.A.B.) extracted and cross-checked the data to identify any discrepancies, which were resolved through re-evaluation of the full texts. A third reviewer (B.T.A.) conducted an additional review of the extracted data to ensure accuracy and identify potential errors The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) quality assessment tool for prevalence studies ( 12 ). The assessment criteria included: representativeness of sample, adequacy of sample size, use of valid measurements, application of appropriate statistical analysis, and response rates. Studies that scored greater than or equal to 50% of the assessment criteria were considered to have a low risk of bias, indicating a high quality, and were included in the meta-analysis. Data analysis Endnote X-8 reference management software was used to organize and manage the selection process. Data analysis was conducted using STATA version 17. Potential publication bias was assessed using the funnel plot ( 13 ) and Egger’s test ( 14 ). The heterogeneity of articles was checked using i 2 statistics ( 15 ). The pooled prevalence of VAP among patients who received mechanical ventilation, along with its 95% confidence interval (CI), was estimated using DerSimonian and Laird’s random-effects model. Subgroup analyses were conducted based on region, population type, and age group. A sensitivity analysis was performed to assess the influence of individual studies on the overall pooled estimate. Results Article selection Using the PRISMA flow diagram, a total of 287 potentially eligible studies were identified. After removing duplications and conducting a full-text review, 22 studies were retrieved. Finally, 7 studies were included for the final review and Meta-analysis (Fig. 1). Figure 1: PRISMA flow chart to illustrate the article selection process Study characteristics All seven studies included in this review and meta-analysis were conducted in Ethiopia and were either published in indexed journals or available as grey literature. All seven studies were cross-sectional and were conducted in Addis Ababa and the Amhara region, with sample sizes ranging from 161 to 434 participants (Table 1 ). Table 1 General characteristics of the included studies Author Publication year Region Age group Sample size Prevalence Study design Quality Tegegne et al., 2025 ( 8 ) 2025 Addis Ababa Adult 341 31.3 Cross- sectional Low risk Bayisa, et al., 2022 ( 16 ) 2022 Addis Ababa Adult 247 46 Cross- sectional Low risk Belay et al., 2022 ( 9 ) 2022 Amhara Adult 312 27.9 Cross- sectional Low risk Atinafu et al., 2024 2024 Addis Ababa Pedi 161 20.5 Cross- sectional Low risk Tadesse et al., 2024 ( 17 ) 2024 Amhara Adult 434 14.6 Cross- sectional Low risk Demem et al, 2024 ( 18 ) 2024 Amhara Adult 391 15.6 Cohort Low risk Tigist B. et al., 2021 ( 19 ) 2021 Addis Ababa Pedi 220 18.6 Cross- sectional Low risk Prevalence of VAP among mechanically ventilated patients In this systematic review and meta-analysis, the pooled prevalence of VAP among mechanically ventilated patients in Ethiopia was estimated at 24.79% (95% CI: 16.60–32.97) using a random-effects model, as illustrated in the forest plot (Fig. 2). Figure 2: Forest plot to depict the pooled prevalence of VAP among mechanically ventilated patients in Ethiopia Subgroup analysis Subgroup analysis by region showed a higher prevalence of VAP among mechanically ventilated patients in Addis Ababa (29.06%; 95% CI: 16.81–41.31) compared to the Amhara region (24.79%; 95% CI: 16.60–32.97) (Fig. 3). Figure 3: Forest plot to depict the pooled prevalence of prevalence of VAP among mechanically ventilated patients by regions in Ethiopia. Similarly, another subgroup analysis using the age of the study population revealed that prevalence of VAP among mechanically ventilated adult patients is higher (26.90; 95% CI: 15.68, 38.12) as compared to pediatrics (24.79%; 95% CI: 16.60, 32.97) (Fig. 4). Figure 4: Forest plot to illustrate the pooled prevalence of prevalence of VAP among mechanically ventilated patients by age group in Ethiopia. Publication bias evaluation The presence of publication bias was evaluated using Egger’s (p = 0.0506) and Begg’s tests (p = 0.2296), which showed that there is no significant publication bias. In addition to the statistical tests, a funnel plot was used, and it is symmetrical. The vertical line indicates the effect size, whereas the diagonal lines indicate the precision of individual studies with a 95% CI (Fig. 5). Figure 5: Funnel plot to illustrate the presence of publication bias Investigation of Heterogeneity A meta-regression analysis using the sample size and publication year was conducted to identify the possible causes of differences between studies. However, the result didn’t show significant heterogeneity (Table 2 ). Table 2 Meta-regression of prevalence of VAP among mechanically ventilated patients with publication year and sample size to detect heterogeneity Source of heterogeneity Coefficients Standard error p-value Publication year − .9192371 3.97455 0. 817 Sample size -. 0286857 .0598395 0. 632 Factors associated with VAP among mechanically ventilated patients Two studies reported on the association between gender and the prevalence of VAP. The meta-analysis showed that male patients had 76% higher odds of developing VAP compared to female patients (OR: 1.76; 95% CI: 1.24, 3.36). Patients who underwent tracheostomy were also more likely to develop VAP compared to those who did not (OR: 6.47; 95% CI: 3.71, 11.27). Additionally, patients who were mechanically ventilated for more than seven days had 5.2 times higher odds of developing VAP compared to those ventilated for less than seven days (OR: 5.18; 95% CI: 2.84, 9.46) (Table 3 ). Table 3 Factors associated with the prevalence of VAP among mechanically ventilated patients in Ethiopia Studies Factors Categories OR 95% CI I 2 Tegegne et al., 2025 Gender Male 1.76 1.24, 2.51 0.00% Belay et al., 2022 Female 1 1 Tegegne et al., 2025 Tracheostomy Yes 6.47 3.71, 11.27 44.9% Belay et al., 2022 No 1 1 Tegegne et al., 2025 Duration of MV ≥ 7 days 6.42 2.89, 9.47 59.9% Belay et al., 2022 < 7 days 1 1 Sensitivity Analysis A sensitivity analysis using the random effect model showed that the single study didn’t affect the pooled prevalence of VAP among mechanically ventilated patients (Fig. 6). Figure 6: The sensitivity analysis to estimate the effect of a single study on the combined prevalence of VAP among mechanically ventilated patients in Ethiopia Discussion Ventilator-associated pneumonia (VAP) is the most frequent and serious hospital-acquired infections among patients receiving mechanical ventilation in Low-and Middle Income Countries (LMICs), particularly in African countries, including Ethiopia ( 11 , 20 ). This systematic review and meta-analysis aimed to the pooled prevalence and factors associated with VAP among mechanically ventilated patients in Ethiopia, provides valuable insights for improving critical care quality and reducing preventable complications. The pooled prevalence of VAP among mechanically ventilated patients was 24.79%, indicating that nearly one in four patients who received mechanical ventilation developed VAP. This finding highlights that VAP remains a significant public health concern in Ethiopian ICUs. The estimated prevalence in this review is comparable to findings reported from other LMICs, where VAP prevalence ranges between 20% and 30% ( 11 , 21 ). For instance, studies conducted in India ( 22 ) and Egypt ( 23 ) have reported the prevalence of VAP was 30.67% and 22%, respectively. A similar systematic review and meta-analysis done in Egypt reported that the prevalence of VAP across Egyptian hospitals ranges from 16% to 75% ( 24 ). The high rates of VAP among mechanically ventilated patients, likely reflecting limited infection control measures, inadequate staffing ratios, and insufficient implementation of VAP prevention bundles ( 25 ). The current review finding is lower than the studies done in India 38% ( 26 ). This could be due the difference in the study period, setting and the population included in the study. However, the result is higher than those reported in developed countries such as the United States (1.8–9.3%) ( 20 , 27 ). A multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East reported that the prevalence of VAP was 2.8% ( 28 ). The lower rates observed in high-income settings may be attributed to stricter adherence to infection prevention protocols, implementation of ventilator care bundles, regular staff training, and better nurse-to-patient ratios, factors often limited in resource-constrained settings like Ethiopia ( 20 ). Subgroup analyses revealed regional variations in the prevalence of VAP. The higher pooled prevalence was observed in Addis Ababa (29.06%), followed by the Amhara region (24.79%). This difference may be attributed to variations in hospital capacity, ICU protocols, patient case-mix, and diagnostic criteria used across regions. Furthermore, the prevalence of VAP was slightly higher among adults (26.90%) than among pediatric patients (24.79%), which could be explained by differences in exposure duration, comorbid conditions, and variations in airway management practices between adult and pediatric ICUs. The assessment of publication bias using Egger’s and Begg’s tests, along with a symmetrical funnel plot, indicated no significant publication bias, supporting the credibility of the pooled prevalence estimate. Meta-regression analysis using publication year and sample size also did not reveal significant sources of heterogeneity, suggesting that the observed variations among studies are not due to methodological differences. Moreover, the sensitivity analysis confirmed the robustness of the pooled result, as no single study significantly influenced the overall estimate. Three factors were found to be significantly associated with the development of VAP. Gender was one significant factor; males had 1.76 times higher odds of developing VAP than females. This finding is supported by the previous similar studies ( 20 , 28 ). This might be related to higher rates of smoking, alcohol use, or underlying chronic diseases among males, which can predispose to respiratory infections. Tracheostomy was also strongly associated with VAP, with patients who underwent tracheostomy having 6.5 times higher odds of developing VAP compared to those who did not. This is consistent with existing evidence showing that tracheostomy can increase the risk of microbial colonization of the lower respiratory tract if proper aseptic techniques and tracheostomy care protocols are not followed ( 29 ). Furthermore, prolonged duration of mechanical ventilation (> 7 days) was significantly associate with VAP, increasing the odds of developing VAP by 5.2 times. This finding aligns with another multination study, which revealed that longer length of stay increased the risk of VAP ( 28 ). Evidence suggesting that prolonged mechanical ventilation increases exposure to potential pathogens and impairs host defenses, particularly in resource-limited settings where routine weaning protocols may not be effectively implemented ( 30 ). Clinical implications The relatively high prevalence of VAP in Ethiopia underscores the need for strengthened infection prevention and control measures in ICUs. Implementation of evidence-based strategies such as the VAP prevention bundle, early weaning protocols, head-of-bed elevation, oral hygiene with chlorhexidine, and staff training can substantially reduce VAP incidence. Moreover, regular surveillance and auditing of VAP rates can help track progress and identify gaps in clinical practice. Limitations of the study This review has some limitations that should be considered when interpreting the findings. First, only studies conducted in Ethiopia were included, which may limit generalizability to other settings. Second, the small number of included studies limited the ability to perform extensive subgroup and meta-regression analyses. Third, we limited the search to English-language articles, so any relevant articles published in foreign languages were not included. Despite these limitations, the study provides valuable pooled estimates and identifies key risk factors relevant to clinical practice. Conclusion and recommendations Approximately one in four mechanically ventilated patients in Ethiopia develop VAP during their stay in the intensive care unit. The risk is notably higher among male patients, those who undergo tracheostomy, and individuals requiring prolonged mechanical ventilation. These findings highlight the considerable burden of VAP and its adverse impact on patient outcomes in Ethiopian ICUs. Therefore, particular attention should be directed toward high-risk groups, specifically males, patients undergoing tracheostomy, and those receiving extended ventilation. Moreover, strengthening infection prevention and control practices and enhancing adherence to evidence-based VAP prevention bundles are essential strategies to reduce the burden of VAP and improve patient outcomes. Declarations Ethical approval and consent to participate Because it is a systematic review and meta-analysis, ethical approval is not applicable. Competing interest The authors declared no competing interests Data availability statement The datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request. Funding Funding not applicable Authors’ contributions M.A.M., B.T.A., and G.T.M. involved in developing the protocol and study design, study selection, data extraction, statistical analysis, and editing of the final manuscript draft. 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Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study. European journal of clinical microbiology & infectious diseases. 2017;36(11):1999-2006. Arabi Y, Al-Shirawi N, Memish Z, Anzueto A. Ventilator-associated pneumonia in adults in developing countries: a systematic review. International journal of infectious diseases. 2008;12(5):505-12. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7950644","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":555371537,"identity":"f112df6e-35c2-469a-b4c8-740e8ded1232","order_by":0,"name":"Mengistu Abebe 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1","display":"","copyAsset":false,"role":"figure","size":278532,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow chart to illustrate the article selection process\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7950644/v1/e535af6280a8c3393fd3c76a.png"},{"id":97894662,"identity":"1403079b-bae9-4554-84d2-454b3edd959f","added_by":"auto","created_at":"2025-12-10 15:32:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":266787,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot to depict the pooled prevalence of VAP among mechanically ventilated patients in Ethiopia\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7950644/v1/8b22eee7c068c371741a0967.png"},{"id":97893874,"identity":"3d1f4de0-6b19-4ed3-82d7-90157b20d702","added_by":"auto","created_at":"2025-12-10 15:31:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":300798,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot to depict the pooled prevalence of prevalence of VAP among mechanically ventilated patients by regions in Ethiopia.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7950644/v1/dfb3fcd244abb246c1ed7cc7.png"},{"id":97892875,"identity":"90efa1a6-0ad8-4648-85d2-bc278873b50d","added_by":"auto","created_at":"2025-12-10 15:23:48","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":224783,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot to illustrate the pooled prevalence of prevalence of VAP among mechanically ventilated patients by age group in Ethiopia.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7950644/v1/2be66a7b2c9b9e1c0a2f40b6.png"},{"id":97695013,"identity":"3037f95b-3c89-42eb-acf5-90fcc669b8da","added_by":"auto","created_at":"2025-12-08 11:28:49","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":158142,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot to illustrate the presence of publication bias\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-7950644/v1/ffea11e6d99ff6ddbfb290c5.png"},{"id":97695015,"identity":"b5c9c848-3a73-4189-b8fd-3643e314fef1","added_by":"auto","created_at":"2025-12-08 11:28:49","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":171840,"visible":true,"origin":"","legend":"\u003cp\u003eThe sensitivity analysis to estimate the effect of a single study on the combined prevalence of VAP among mechanically ventilated patients in Ethiopia\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-7950644/v1/9db1dbc85f7c31407ba6a1bf.png"},{"id":108473178,"identity":"3fd31088-2b48-4b20-8262-0a05ed370315","added_by":"auto","created_at":"2026-05-05 06:11:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1864252,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7950644/v1/d8c0adf2-5609-46e7-b465-82db562854c8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The prevalence of Ventilator-Associated Pneumonia (VAP) and its associated factors among mechanically ventilated patients in Ethiopia. A systematic review and meta-analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eVentilator-associated pneumonia (VAP) is a common and serious nosocomial infection that occurs in patients receiving mechanical ventilation for at least 48 hours (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is one of the most common and serious nosocomial infections among patients receiving mechanical ventilation in Intensive Care Units (ICUs) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It associated with increased morbidity, longer hospitalizations, higher healthcare costs, and increased mortality rates worldwide (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn low- and middle-income countries, including Ethiopia, the burden of VAP is often underestimated due to limited surveillance, diagnostic challenges, and variable infection control practices (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Previous studies in Ethiopia have reported varying prevalence rates and identified several risk factors, including age, sex, duration of ventilation, poor oral hygiene, underlying comorbidities, re-intubation, tracheostomy care, and the use of broad-spectrum antibiotics (\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Despite several individual studies reporting the prevalence and risk factors of VAP in different regions of Ethiopia, the findings are inconsistent, with substantial variation in reported prevalence rates. Additionally, the specific factors that increase the risk of VAP have not been systematically synthesized. This lack of comprehensive evidence hinders the development of standardized prevention protocols and targeted interventions, leaving patients vulnerable to preventable complications.\u003c/p\u003e\u003cp\u003eUnderstanding these the prevalence and its determinants is crucial for guiding effective infection prevention strategies, improving patient outcomes, and guiding healthcare policy and resource allocation. Therefore, this systematic review and meta-analysis aims to estimate the pooled prevalence of VAP and identify its associated factors among mechanically ventilated patients in Ethiopia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy registration and reporting protocol\u003c/h2\u003e\u003cp\u003eThis systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure transparency and standardized reporting.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSearching strategy\u003c/h3\u003e\n\u003cp\u003eFollowing the PRISMA guidelines, a comprehensive literature search was conducted in PubMed, Web of Science, Scopus, CINAHL, EMBASE, HINARI, and Google Scholar without restriction on publication year. To capture unpublished studies and grey literature, Google Scholar was also searched up to September 30, 2025. All retrieved studies, both published and grey literature, were critically evaluated for eligibility.\u003c/p\u003e\u003cp\u003eThe search strategy employed a combination of Medical Subject Headings (MeSH) terms and keywords related to \u0026ldquo;ventilator-associated pneumonia,\u0026rdquo; \u0026ldquo;VAP,\u0026rdquo; \u0026ldquo;mechanical ventilation,\u0026rdquo; and \u0026ldquo;Ethiopia.\u0026rdquo; Reference lists of eligible articles were manually screened to identify additional relevant studies. The CoCoPoP framework was used to structure the search terms as follows: (\u003cb\u003eCondition\u003c/b\u003e: \u0026ldquo;ventilator-associated pneumonia,\u0026rdquo; \u0026ldquo;VAP,\u0026rdquo; \u0026ldquo;nosocomial pneumonia,\u0026rdquo; \u0026ldquo;hospital-acquired pneumonia;\u0026rdquo; \u003cb\u003eContext\u003c/b\u003e: \u0026ldquo;Ethiopia,\u0026rdquo; \u0026ldquo;Ethiopian hospitals,\u0026rdquo; \u0026ldquo;intensive care unit,\u0026rdquo; \u0026ldquo;ICU,\u0026rdquo; and \u0026ldquo;critical care;\u0026rdquo; \u003cb\u003ePopulation\u003c/b\u003e: mechanically ventilated patients,\u0026rdquo; \u0026ldquo;intubated patients,\u0026rdquo; and \u0026ldquo;ventilated patients\u0026rdquo;). Boolean operators (\u0026ldquo;AND\u0026rdquo; and/or \u0026ldquo;OR\u0026rdquo;) were applied to combine search terms and optimize retrieval of relevant studies.\u003c/p\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eThis review included observational studies, prospective and retrospective cohort, cross-sectional, and case-control designs, that reported the prevalence of VAP and its associated factors among mechanically ventilated patients in Ethiopia. Articles that did not provide a full access, case reports, and letters were excluded.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome of this review was the prevalence of VAP in Ethiopia, reported as both a percentage and a frequency in the included studies. The secondary outcome was the identification of factors associated with VAP. To enhance the validity of the analysis, only factors reported in at least two studies were included in the pooled analysis.\u003c/p\u003e\n\u003ch3\u003eData extraction and data quality assessment\u003c/h3\u003e\n\u003cp\u003eThe articles identified through the literature search were initially screened by title and abstract for eligibility in the systematic review by independent reviewers (M.A.M., T.A.B., and B.T.A.). Studies that met the inclusion criteria during this initial screening were subjected to full-text review. The full texts of eligible studies were independently assessed by a separate group of reviewers (G.T.M., K.S.W., G.B.M., M.M.T., A.G., H.A.A., and M.G.) to determine their inclusion in the final analysis. Any disagreements were resolved by referring to the predefined inclusion and exclusion criteria, with a third reviewer (M.L.) making the final decision when necessary.\u003c/p\u003e\u003cp\u003eData extraction was performed using Microsoft Excel 2019, capturing information on the author, publication year, study region, prevalence of VAP, sample size, study design, and population group. Two independent reviewers (M.A.M. and T.A.B.) extracted and cross-checked the data to identify any discrepancies, which were resolved through re-evaluation of the full texts. A third reviewer (B.T.A.) conducted an additional review of the extracted data to ensure accuracy and identify potential errors\u003c/p\u003e\u003cp\u003eThe quality of the included studies was assessed using the Joanna Briggs Institute (JBI) quality assessment tool for prevalence studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The assessment criteria included: representativeness of sample, adequacy of sample size, use of valid measurements, application of appropriate statistical analysis, and response rates. Studies that scored greater than or equal to 50% of the assessment criteria were considered to have a low risk of bias, indicating a high quality, and were included in the meta-analysis.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eEndnote X-8 reference management software was used to organize and manage the selection process. Data analysis was conducted using STATA version 17. Potential publication bias was assessed using the funnel plot (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and Egger\u0026rsquo;s test (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The heterogeneity of articles was checked using i\u003csup\u003e2\u003c/sup\u003e statistics (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The pooled prevalence of VAP among patients who received mechanical ventilation, along with its 95% confidence interval (CI), was estimated using DerSimonian and Laird\u0026rsquo;s random-effects model. Subgroup analyses were conducted based on region, population type, and age group. A sensitivity analysis was performed to assess the influence of individual studies on the overall pooled estimate.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eArticle selection\u003c/h2\u003e\u003cp\u003eUsing the PRISMA flow diagram, a total of 287 potentially eligible studies were identified. After removing duplications and conducting a full-text review, 22 studies were retrieved. Finally, 7 studies were included for the final review and Meta-analysis (Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eFigure 1: PRISMA flow chart to illustrate the article selection process\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStudy characteristics\u003c/h2\u003e\u003cp\u003eAll seven studies included in this review and meta-analysis were conducted in Ethiopia and were either published in indexed journals or available as grey literature. All seven studies were cross-sectional and were conducted in Addis Ababa and the Amhara region, with sample sizes ranging from 161 to 434 participants (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGeneral characteristics of the included studies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePublication year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRegion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAge group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSample size\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePrevalence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eStudy design\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eQuality\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTegegne\u0026nbsp;et\u0026nbsp;al., 2025 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAddis Ababa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e341\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCross- sectional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow risk\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBayisa, et al., 2022 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAddis Ababa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCross- sectional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow risk\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBelay et al., 2022 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAmhara\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e312\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCross- sectional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow risk\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtinafu et al., 2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAddis Ababa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePedi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCross- sectional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow risk\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTadesse et al., 2024 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAmhara\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e434\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCross- sectional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow risk\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemem et al, 2024 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAmhara\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e391\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCohort\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow risk\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTigist B. et al., 2021 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAddis Ababa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePedi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e220\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCross- sectional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLow risk\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePrevalence of VAP among mechanically ventilated patients\u003c/h2\u003e\u003cp\u003eIn this systematic review and meta-analysis, the pooled prevalence of VAP among mechanically ventilated patients in Ethiopia was estimated at 24.79% (95% CI: 16.60\u0026ndash;32.97) using a random-effects model, as illustrated in the forest plot (Fig.\u0026nbsp;2).\u003c/p\u003e\u003cp\u003eFigure 2: Forest plot to depict the pooled prevalence of VAP among mechanically ventilated patients in Ethiopia\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSubgroup analysis\u003c/h2\u003e\u003cp\u003eSubgroup analysis by region showed a higher prevalence of VAP among mechanically ventilated patients in Addis Ababa (29.06%; 95% CI: 16.81\u0026ndash;41.31) compared to the Amhara region (24.79%; 95% CI: 16.60\u0026ndash;32.97) (Fig.\u0026nbsp;3).\u003c/p\u003e\u003cp\u003eFigure 3: Forest plot to depict the pooled prevalence of prevalence of VAP among mechanically ventilated patients by regions in Ethiopia.\u003c/p\u003e\u003cp\u003eSimilarly, another subgroup analysis using the age of the study population revealed that prevalence of VAP among mechanically ventilated adult patients is higher (26.90; 95% CI: 15.68, 38.12) as compared to pediatrics (24.79%; 95% CI: 16.60, 32.97) (Fig.\u0026nbsp;4).\u003c/p\u003e\u003cp\u003eFigure 4: Forest plot to illustrate the pooled prevalence of prevalence of VAP among mechanically ventilated patients by age group in Ethiopia.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePublication bias evaluation\u003c/h2\u003e\u003cp\u003eThe presence of publication bias was evaluated using Egger\u0026rsquo;s (p\u0026thinsp;=\u0026thinsp;0.0506) and Begg\u0026rsquo;s tests (p\u0026thinsp;=\u0026thinsp;0.2296), which showed that there is no significant publication bias. In addition to the statistical tests, a funnel plot was used, and it is symmetrical. The vertical line indicates the effect size, whereas the diagonal lines indicate the precision of individual studies with a 95% CI (Fig.\u0026nbsp;5).\u003c/p\u003e\u003cp\u003eFigure 5: Funnel plot to illustrate the presence of publication bias\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eInvestigation of Heterogeneity\u003c/h2\u003e\u003cp\u003eA meta-regression analysis using the sample size and publication year was conducted to identify the possible causes of differences between studies. However, the result didn\u0026rsquo;t show significant heterogeneity (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMeta-regression of prevalence of VAP among mechanically ventilated patients with publication year and sample size to detect heterogeneity\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSource of heterogeneity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCoefficients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStandard error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePublication year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.9192371\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.97455\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0. 817\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSample size\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-. 0286857\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.0598395\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0. 632\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with VAP among mechanically ventilated patients\u003c/h2\u003e\u003cp\u003eTwo studies reported on the association between gender and the prevalence of VAP. The meta-analysis showed that male patients had 76% higher odds of developing VAP compared to female patients (OR: 1.76; 95% CI: 1.24, 3.36). Patients who underwent tracheostomy were also more likely to develop VAP compared to those who did not (OR: 6.47; 95% CI: 3.71, 11.27). Additionally, patients who were mechanically ventilated for more than seven days had 5.2 times higher odds of developing VAP compared to those ventilated for less than seven days (OR: 5.18; 95% CI: 2.84, 9.46) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with the prevalence of VAP among mechanically ventilated patients in Ethiopia\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFactors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTegegne et al., 2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.24, 2.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.00%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBelay et al., 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTegegne et al., 2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTracheostomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.71, 11.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e44.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBelay et al., 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTegegne et al., 2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDuration of MV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;7 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.89, 9.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e59.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBelay et al., 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;7 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eSensitivity Analysis\u003c/h2\u003e\u003cp\u003eA sensitivity analysis using the random effect model showed that the single study didn\u0026rsquo;t affect the pooled prevalence of VAP among mechanically ventilated patients (Fig.\u0026nbsp;6).\u003c/p\u003e\u003cp\u003eFigure 6: The sensitivity analysis to estimate the effect of a single study on the combined prevalence of VAP among mechanically ventilated patients in Ethiopia\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eVentilator-associated pneumonia (VAP) is the most frequent and serious hospital-acquired infections among patients receiving mechanical ventilation in Low-and Middle Income Countries (LMICs), particularly in African countries, including Ethiopia (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This systematic review and meta-analysis aimed to the pooled prevalence and factors associated with VAP among mechanically ventilated patients in Ethiopia, provides valuable insights for improving critical care quality and reducing preventable complications.\u003c/p\u003e\u003cp\u003eThe pooled prevalence of VAP among mechanically ventilated patients was 24.79%, indicating that nearly one in four patients who received mechanical ventilation developed VAP. This finding highlights that VAP remains a significant public health concern in Ethiopian ICUs. The estimated prevalence in this review is comparable to findings reported from other LMICs, where VAP prevalence ranges between 20% and 30% (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). For instance, studies conducted in India (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and Egypt (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) have reported the prevalence of VAP was 30.67% and 22%, respectively. A similar systematic review and meta-analysis done in Egypt reported that the prevalence of VAP across Egyptian hospitals ranges from 16% to 75% (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The high rates of VAP among mechanically ventilated patients, likely reflecting limited infection control measures, inadequate staffing ratios, and insufficient implementation of VAP prevention bundles (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The current review finding is lower than the studies done in India 38% (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This could be due the difference in the study period, setting and the population included in the study. However, the result is higher than those reported in developed countries such as the United States (1.8–9.3%) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). A multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East reported that the prevalence of VAP was 2.8% (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The lower rates observed in high-income settings may be attributed to stricter adherence to infection prevention protocols, implementation of ventilator care bundles, regular staff training, and better nurse-to-patient ratios, factors often limited in resource-constrained settings like Ethiopia (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSubgroup analyses revealed regional variations in the prevalence of VAP. The higher pooled prevalence was observed in Addis Ababa (29.06%), followed by the Amhara region (24.79%). This difference may be attributed to variations in hospital capacity, ICU protocols, patient case-mix, and diagnostic criteria used across regions. Furthermore, the prevalence of VAP was slightly higher among adults (26.90%) than among pediatric patients (24.79%), which could be explained by differences in exposure duration, comorbid conditions, and variations in airway management practices between adult and pediatric ICUs.\u003c/p\u003e\u003cp\u003eThe assessment of publication bias using Egger’s and Begg’s tests, along with a symmetrical funnel plot, indicated no significant publication bias, supporting the credibility of the pooled prevalence estimate. Meta-regression analysis using publication year and sample size also did not reveal significant sources of heterogeneity, suggesting that the observed variations among studies are not due to methodological differences. Moreover, the sensitivity analysis confirmed the robustness of the pooled result, as no single study significantly influenced the overall estimate.\u003c/p\u003e\u003cp\u003eThree factors were found to be significantly associated with the development of VAP. Gender was one significant factor; males had 1.76 times higher odds of developing VAP than females. This finding is supported by the previous similar studies (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This might be related to higher rates of smoking, alcohol use, or underlying chronic diseases among males, which can predispose to respiratory infections.\u003c/p\u003e\u003cp\u003eTracheostomy was also strongly associated with VAP, with patients who underwent tracheostomy having 6.5 times higher odds of developing VAP compared to those who did not. This is consistent with existing evidence showing that tracheostomy can increase the risk of microbial colonization of the lower respiratory tract if proper aseptic techniques and tracheostomy care protocols are not followed (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFurthermore, prolonged duration of mechanical ventilation (\u0026gt; 7 days) was significantly associate with VAP, increasing the odds of developing VAP by 5.2 times. This finding aligns with another multination study, which revealed that longer length of stay increased the risk of VAP (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Evidence suggesting that prolonged mechanical ventilation increases exposure to potential pathogens and impairs host defenses, particularly in resource-limited settings where routine weaning protocols may not be effectively implemented (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eClinical implications\u003c/h2\u003e\u003cp\u003eThe relatively high prevalence of VAP in Ethiopia underscores the need for strengthened infection prevention and control measures in ICUs. Implementation of evidence-based strategies such as the VAP prevention bundle, early weaning protocols, head-of-bed elevation, oral hygiene with chlorhexidine, and staff training can substantially reduce VAP incidence. Moreover, regular surveillance and auditing of VAP rates can help track progress and identify gaps in clinical practice.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eLimitations of the study\u003c/h2\u003e\u003cp\u003eThis review has some limitations that should be considered when interpreting the findings. First, only studies conducted in Ethiopia were included, which may limit generalizability to other settings. Second, the small number of included studies limited the ability to perform extensive subgroup and meta-regression analyses. Third, we limited the search to English-language articles, so any relevant articles published in foreign languages were not included. Despite these limitations, the study provides valuable pooled estimates and identifies key risk factors relevant to clinical practice.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion and recommendations","content":"\u003cp\u003eApproximately one in four mechanically ventilated patients in Ethiopia develop VAP during their stay in the intensive care unit. The risk is notably higher among male patients, those who undergo tracheostomy, and individuals requiring prolonged mechanical ventilation. These findings highlight the considerable burden of VAP and its adverse impact on patient outcomes in Ethiopian ICUs. Therefore, particular attention should be directed toward high-risk groups, specifically males, patients undergoing tracheostomy, and those receiving extended ventilation. Moreover, strengthening infection prevention and control practices and enhancing adherence to evidence-based VAP prevention bundles are essential strategies to reduce the burden of VAP and improve patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBecause it is a systematic review and meta-analysis, ethical approval is not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.A.M., B.T.A., and G.T.M. involved in developing the protocol and study design, study selection, data extraction, statistical analysis, and editing of the final manuscript draft. M.G. and A.G.: involved in quality assessment, statistical analysis, and manuscript revision., T.A.B., M.A.M., K.S.W., M.L., M.M.T., H.A.A., G.B.M., and M.G: study selection and extraction; took part in drafting the manuscript or revising it critically for important intellectual content; agreed to submit it to the current journal; gave final approval of the version to be published; and agreed to be accountable for all aspects of the work.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbd-Elmonsef MM, Elsharawy D, Abd-Elsalam AS. Mechanical ventilator as a major cause of infection and drug resistance in intensive care unit. Environmental Science and Pollution Research. 2018;25(31):30787-92.\u003c/li\u003e\n\u003cli\u003eTrubiano JA, Padiglione AA. Nosocomial infections in the intensive care unit. Anaesthesia \u0026amp; Intensive Care Medicine. 2015;16(12):598-602.\u003c/li\u003e\n\u003cli\u003eSafdar N, Dezfulian C, Collard HR, Saint S. 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Microbiological profile of ventilator-associated pneumonia among intensive care unit patients in tertiary Egyptian hospitals. The Journal of Infection in Developing Countries. 2020;14(02):153-61.\u003c/li\u003e\n\u003cli\u003eMathai AS, Phillips A, Isaac R. Ventilator-associated pneumonia: A persistent healthcare problem in Indian Intensive Care Units! Lung India. 2016;33(5):512-6.\u003c/li\u003e\n\u003cli\u003eRello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122(6):2115-21.\u003c/li\u003e\n\u003cli\u003eRosenthal VD, Jin Z, Memish ZA, Rodrigues C, Myatra SN, Kharbanda M, et al. Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East: Findings of the International Nosocomial Infection Control Consortium (INICC). Antimicrobial Stewardship \u0026amp; Healthcare Epidemiology. 2023;3(1):e6.\u003c/li\u003e\n\u003cli\u003eKoulenti D, Tsigou E, Rello J. Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study. European journal of clinical microbiology \u0026amp; infectious diseases. 2017;36(11):1999-2006.\u003c/li\u003e\n\u003cli\u003eArabi Y, Al-Shirawi N, Memish Z, Anzueto A. Ventilator-associated pneumonia in adults in developing countries: a systematic review. International journal of infectious diseases. 2008;12(5):505-12.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ventilator-associated pneumonia, VAP, Prevalence, Meta-analysis, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-7950644/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7950644/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eVentilator-associated pneumonia (VAP) is a common nosocomial infection that occurs in critically ill patients who are on mechanical ventilation. Despite the growing number of individual studies, there is a lack of comprehensive synthesis of evidence on the prevalence and associated factors of ventilator-associated pneumonia in Ethiopia. Insight into these patterns is crucial to informing effective infection prevention strategies, optimizing patient outcomes, and guiding evidence-based clinical practice and resource allocation. Therefore, this study aimed to assess the prevalence and associated factors of ventilator-associated pneumonia in Ethiopia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This systematic review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A structured search of databases (PubMed, Google Scholar, CINAHL, Scopus, HINARI, African Journal of Online (AJOL), and Web of Science) was undertaken. The quality of the included studies was independently evaluated by two reviewers using validated critical appraisal instruments. A meta-analysis using a random-effects model was conducted to estimate the pooled prevalence. Heterogeneity among studies was assessed using the I² statistic. To identify the potential sources of heterogeneity, subgroup analyses and meta-regression were performed. Publication bias was evaluated using Egger’s test and visual inspection of funnel plots. All statistical analyses were conducted using STATA version 17.0.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of seven studies comprising 2,106 participants were included in the analysis. The pooled prevalence of ventilator-associated pneumonia among mechanically ventilated patients in Ethiopia was 24.79% (95% CI: 16.60, 32.97), as estimated using a random-effects model.\u003c/p\u003e\n\u003cp\u003eRegional subgroup analysis revealed that the highest prevalence of VAP was observed in Addis Ababa (29.06%; 95% CI: 16.81, 41.31), followed by the Amhara region (24.79%; 95% CI: 16.60, 32.97). Subgroup analysis by age group indicated that the prevalence of VAP was higher among adult patients (26.90%; 95% CI: 15.68, 38.12) compared with pediatric patients (24.79%; 95% CI: 16.60, 32.97).\u003c/p\u003e\n\u003cp\u003eBeing male increased the odds of developing VAP by 76% compared to females (OR: 1.76, 95% CI: 1.24, 3.36), patients who undergoing tracheostomy were 6.5 times higher odds of developing VAP compared to their counterparts (OR: 6.47, 95% CI: 3.71, 11.27), and patients who ventilated more than 7 days had 5.2 times higher odds of developing VAP compared to those who ventilated fewer than 7 days (OR: 5.18, 95% CI: 2.84, 9.46).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion and recommendations: \u003c/strong\u003eNearly one in four mechanically ventilated patients in Ethiopia develop VAP during intensive care unit admission. The risk is particularly high among males, patients undergoing tracheostomy, and those requiring prolonged mechanical ventilation. These findings underscore the substantial burden of VAP and its impact on patient outcomes in Ethiopian intensive care units. Therefore, special attention should be given to males, patients undergoing tracheostomy, and those on prolonged mechanical ventilation. In addition, strengthening infection control measures and improve the implementation of VAP prevention bundles are critical to mitigating the burden of VAP and improving patient outcomes.\u003c/p\u003e","manuscriptTitle":"The prevalence of Ventilator-Associated Pneumonia (VAP) and its associated factors among mechanically ventilated patients in Ethiopia. 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