JAC Advance Access published online on May 31, 2007
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkm176
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Review |
Hospital-acquired pneumonia guidelines in Europe: a review of their status and future development
1 NHS Ayrshire and Arran, Eglington House, Ailsa Hospital, Dalmellington Road, Ayr KA6 0BA, UK 2 Lahey Clinic Medical Center, Burlington, MA, USA 3 Tufts University School of Medicine, Boston, MA, USA 4 Joan XXIII University Hospital, University Rovira and Virgili, CIBERes 06-06-0036, Tarragona, Spain 5 Hôpital Erasme, Belgium 6 National Centre for Antimicrobial Infection Control, Copenhagen, Denmark 7 GH Pitié-Salpêtrière, AP-HP, Paris, France 8 Karolinska Institutet Stockholm, Stockholm, Sweden 9 University of Verona, Verona, Italy 10 City Hospital, Berlin, Germany 11 Attikon University Hospital, Athens, Greece 12 University Medical Center, Utrecht, The Netherlands 13 Istanbul University, Istanbul, Turkey 14 University of Dundee, Dundee, Scotland, UK
* Corresponding author. Tel: +44-1292-614510; Fax: +44-1292-288952; E-mail: robert.masterton{at}aaaht.scot.nhs.uk
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Abstract |
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Top
Abstract
IntroductionHospital-acquired pneumonia (HAP) is the most common healthcare-acquired infection contributing to death. Effective management requires accurate diagnosis, administration of a suitable antibiotic regimen early in infection and implementation of prevention strategies. In recent years, there has been a rapid increase in the number of country-specific HAP guidelines in Europe, which vary in their formulation, coverage of different disease aspects and overall recommendations. Development of comprehensive pan-European HAP guidelines would rationalize the conflicting proposals, provide a useful resource and limit guideline proliferation. However, careful consideration needs to be given to the principles of guideline development to ensure that the output is rigorous, broadly applicable and facilitates update as new data becomes available. The use of an evidence-based approach to HAP guideline development is optimal, but is compromised by limitations in the supporting data. The implementation of a formalized evidence grading system is key to introducing consistency into the guideline development process. Pan-European guidelines should provide recommendations on core aspects of HAP common to all treatment settings and locations, and reflect the differing perspectives of the countries involved. Given the different antibiotic susceptibility profiles across Europe, such guidelines should provide general treatment recommendations suitable for local adaptation. The development of such guidelines represents an ideal time to identify priorities for European research, by addressing controversies and identifying previously unconsidered aspects of HAP. Establishing a pan-European consensus on core processes of care should be viewed as an impetus for change to improve clinical practices and should include a suitable implementation strategy.
Key Words: European consensus , guideline development , implementation
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Introduction |
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Hospital-acquired pneumonia (HAP) is a respiratory infection developing more than 48 h after hospital admission and affects 0.5% to 1.7% of patients.1–4 HAP is the most common healthcare-acquired infection contributing to death5,6 and is estimated to increase hospital stay by 7–9 days.7,8 In a proportion of patients, HAP is associated with mechanical ventilation, in which case it is termed as ventilator-associated pneumonia (VAP).9 In patients with VAP there is a 20% to 55% mortality rate and a mean increase in the duration of hospital stay of 6 days.10 Mortality increases to 76% if infection is caused by multidrug-resistant pathogens.11 Healthcare-associated pneumonia (HCAP) is now recognized as a particular subtype of HAP occurring in patients who have resided in an acute care hospital for two or more days within 90 days of infection; have resided in a nursing home or long-term care facility; have received intravenous antibiotic therapy, chemotherapy or wound care within 30 days of the infection; or who regularly attend a hospital or haemodialysis clinic.12 The identification of this group recognizes a cohort of patients lying between community and hospital practice, in terms of a risk of infection, with difficult to treat and potentially more antibiotic-resistant pathogens.
Effective management of HAP requires accurate diagnosis, administration of a suitable antibiotic regimen during the early stages of infection and implementation of optimal prevention strategies. An increasing body of evidence demonstrates that delayed HAP treatment or use of an inappropriate antibiotic dramatically increases mortality.13 The need for effective HAP management has led to the publication of numerous guidelines since 2000, but these are often limited in the issues considered and sometimes present conflicting recommendations.4 In May 2006, a group met to consider the current status of European country-specific HAP guidelines and the possibility of developing an overarching pan-European consensus document, to comprehensively address current HAP issues. A potential model for such a consensus document comprises the care bundle strategy, as has already been applied to VAP in the USA.14 This strategy approach aims to maximize patient benefit by identifying a small number of simple, effective and robust key core care elements, with a view to targeting these for universal adoption.
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Existing European HAP guidelines |
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In recent years, there has been a rapid increase in the number of country-specific HAP guidelines produced. In order to review the current situation, meeting participants from across Europe provided information detailing the scope and recommendations of any national/institutional HAP guidelines produced in their respective countries. Of the 11 countries represented, a total of 10 had developed HAP guidelines over the last 4 years, as summarized in Table 1. HAP guidelines were developed by working parties composed primarily of intensivists, microbiologists, infectious disease specialists and respiratory physicians, as detailed in Table 2, with minimal involvement of radiologists, infection control nurses, pharmacists, surgeons or lay persons.
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The main challenge to the development of HAP guidelines was perceived to be the mass and complexity of the supporting evidence. Assessment of this body of supporting data is associated with a substantial time burden and, as a result, evidence grading was only implemented for five country-specific guidelines. The draft UK15 guidelines adopted the formalized Scottish Intercollegiate Guidelines Network (SIGN) assessment methodology, which undertakes a systematic review and grades both the evidence base and the strength of the resultant recommendations. Germany,16 The Netherlands,17 Spain18 and Sweden19 graded the evidence, however, there was no consistency in the grading procedures used: Spain graded evidence using a four-point scale comprising (i) scientific opinion, (ii) scientific opinion with expert opinion, (iii) expert opinion and (iv) absence of expert opinion. Sweden used a three-point system comprising (i) strong scientific evidence from clinical studies, (ii) some evidence from clinical studies, or strong evidence from experimental studies and (iii) expert opinion. Germany and The Netherlands used four- and five-point grading systems, respectively. Of these only Germany used a systematic review process to develop guideline recommendations. As a result of the difficulties inherent in evidence grading, the other country-specific guideline recommendations were developed based on consensus/expert opinion. Despite these differences in the approach to HAP guideline development, there was often concordance in the recommendations produced.
A structured questionnaire was used to determine the aspects of HAP addressed by the country-specific guidelines. HAP guidelines were usually divided into themes of diagnosis, prevention and treatment, and six of the countries surveyed addressed all of these aspects. Other themes considered by some guidelines comprised epidemiology (two guidelines), non-response to treatment (one guideline) and treatment dosages (one guideline).
HAP diagnosis (eight guidelines)
A universal problem associated with development of the diagnostic HAP guidelines was interpreting weak data. Almost all research in this area relates to VAP and the validity of its extrapolation to HAP is uncertain. Some systematic reviews and randomized clinical trials (RCTs) into investigational methods are available but most recommendations are opinion based. There was a high degree of consistency between countries in common aspects covered by all guidelines, which included radiological imaging, clinical diagnostic criteria, microbiological surveillance and microbiological assessment of respiratory secretions. In addition, six guidelines assessed diagnostic lung histology despite the method not being routinely used. Generally the different country-specific guidelines concurred that HAP diagnosis should be directed by clinical, imaging and microbiological findings. However other issues, in particular the applicability of quantitative microbiological sample assessment, were more controversial.
HAP treatment (eight guidelines)
Similarly, the development of the HAP treatment guidelines was compromised by much of the supporting evidence being based on expert opinion and, again, the literature primarily dealt with VAP. Many of the RCTs available were earlier studies evaluating antibiotics, which due to changes in the nature and susceptibility patterns of the causative agents, are no longer regarded as appropriate therapy for HAP. HAP treatment guidelines were reasonably consistent in the themes covered, with all addressing the use of invasive microbiology findings to direct therapy and the principles of antibiotic therapy for HAP patients. Other areas commonly considered included assessing treatment response (seven guidelines), selective digestive tract decontamination (SDD, six guidelines), prophylaxis (five guidelines), instilled or nebulized therapy (five guidelines) and step-down treatment from intravenous to oral regimens (four guidelines). The use of non-antibiotic regimens to treat HAP was only addressed by two guidelines.
When considering HAP treatment, an obvious area of difference between countries was associated with the different microbial antibiotic resistance profiles occurring across Europe. Differences in antibiotic resistance profiles, even within individual countries, were noted as being problematical when developing treatment guidelines. As a result, most country-specific HAP guidelines indicated that the empirical treatment of choice should be determined based on current, local antibiotic susceptibility profiles and patient risk factors. Only three countries specified the administration of particular antimicrobial agents, the choice of which usually depended on whether HAP was early or late onset. The other main area of controversy between country-specific guidelines was whether a policy of antibiotic dose de-escalation should be implemented.
HAP prevention (eight guidelines)
The evidence base for HAP prevention guidelines comprised some systematic reviews and RCTs covering a broad range of issues, though most of the data were in the form of cohort or case studies and again related to VAP. HAP prevention guidelines covered a wide range of themes that could be grouped into areas of educational aspects, ventilation, patient process interventions and adjunctive care. The only aspects that received universal coverage were the use of positional strategies and preventing aspiration. Because of the wide range of themes covered, there was little consistency in terms of the recommendations given by the different country-specific guidelines. The only areas where recommendations were routinely in agreement comprised the applicability of hand hygiene measures, the preferential use of non-invasive ventilation and the appropriateness of patient positioning strategies. A degree of controversy was associated with recommendations considering stress ulcer prophylaxis, the use of heat moisture exchanger circuits and SDD.
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Model guidelines |
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Learned societies such as ESCMID25 have recognized that the development of core pan-European HAP guidelines would provide a useful resource and would limit the constant proliferation of new guidelines. However, careful consideration needs to be given to the principles behind the guideline development process, to ensure that the output is rigorous, comprehensive and broadly applicable. In addition, the guideline development methodology should facilitate regular update as the evidence base develops. It was felt that the available guidelines were a reliable and viable basis for development of a consensus guideline and that there would be no benefit in repeating the exhaustive literature reviews already captured in the existing documents. Indeed trans-contextual adaptation of guidelines is increasingly being considered as an alternative to de novo guideline development, and recent guidance suggests an appropriate approach.26
The development of comprehensive HAP guidelines is complicated by issues that are associated with the quality of the supporting evidence. Few systematic reviews are available, with a predominance of observational studies.12 Although some RCTs are available, the data are often compromised by small patient numbers where study inclusion is based on the presence of specific pathogens. In addition, the absence of prospective analysis of the effects of treatment dose or regimen and the lack of any consideration of patient demography, risk factors or disease severity undermine the weight that can be placed on the findings. These problems are exacerbated by the tendency to design one-to-one treatment comparisons, especially as equivalence studies in support of licensing applications, rather than multi-treatment effectiveness comparisons.
Because of the limitations in the HAP evidence base it is often difficult to produce quality recommendations. The implementation of a formalized grading system introduces consistency into the evidence assessment process, which is particularly advantageous where quality data are lacking. The meeting participants noted the lack of agreement about what represents a suitable, systematic data review process as being a major limitation curtailing the development of rigorous evidence-based guidelines.
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Approaches to guideline development |
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The Scottish Intercollegiate Guidelines Network approach
SIGN has been developing standardized methodologies for clinical guideline production since 1999, and has implemented mechanisms for assessing the quality of the evidence base and grading the strength of the resulting recommendations.27 The SIGN approach to evidence synthesis involves using an explicit search strategy, to identify relevant data, and weights the literature according to a hierarchical structure with systematic reviews and meta-analyses of RCTs having greatest impact. Evidence statements are developed for the specific issues under consideration and these are used to derive guideline recommendations. The guidelines are then graded to differentiate those based on strong evidence from those based on weak evidence.
The SIGN process aims to generate evidence-based guidelines, placing minimal weight on expert opinion, and was used during the development of the UK HAP guidelines.15 This type of comprehensive, formalized grading of the evidence is advantageous when updating guidelines. The use of data-sharing strategies with a central evidence database means that new data can be readily added to that previously assessed, thereby facilitating revision.
The American Thoracic Society/Infectious Diseases Society of America approach
The American Thoracic Society/Infectious Diseases Society of America used a more simplistic approach to evidence grading during its HAP guideline development.12 Committee members were allocated a topic to review and the evidence was graded as:
- Level 1 (high)—comprising well-conducted RCTs.
- Level 2 (moderate)—comprising well-conducted, non-randomized controlled trials, systematic analysis of large case series or reports of new therapies.
- Level 3 (low)—comprising case studies, expert opinion or antibiotic susceptibility data without clinical observations.
Recommendations were formulated following committee discussion of the data supporting each topic, with the level of evidence supporting each recommendation being explicitly stated.
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Principles for HAP guidelines |
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The meeting participants considered that in the HAP setting, the use of an evidence-based approach to guideline development is optimal, but that expert opinion can be used to guide assessment when quality data are lacking as long as the impact of the resulting recommendations is graded accordingly. When considering the production of pan-European HAP guidelines, the involvement of experts from diverse geographical locations was considered optimal for ensuring the applicability of the resulting outcomes. It was recognized that the pharmaceutical industry has a strong history of providing support for guidelines. Though such support was acknowledged to be non-restrictive, the group reflected upon the possibility of negative perceptions being associated with such assistance and considered that guideline development should be independent of industry support. The group reviewed the areas of HAP diagnosis, treatment and prevention to identify the key guideline construction issues to be addressed.
Guidelines should define triggers that would initiate diagnostic tests for suspected HAP using clinical scoring systems, specialist imaging techniques, risk factors for pneumonia, the presence of specific causative agents (including antibiotic-resistant organisms) and non-specific biological markers. Specific questions concerning the applicability of diagnostic tests to be considered included:
- The feasibility and limitations of imaging techniques in the intensive care setting.
- Differentiating the roles of X-ray, magnetic resonance imaging and computed tomography.
- The applicability of invasive and non-invasive microbiological sampling techniques.
- The timing of microbiological sampling.
- The effectiveness of quantitative, semi-quantitative and qualitative culture methods.
- The use of urinary antigen tests for specific pathogens.
- The use of molecular detection methods.
The role of microbial surveillance is also a key area requiring consideration as it supports empirical treatment selection for the individual patient and provides epidemiological data to direct infection control measures and antibiotic usage policy.
Given the differences in antibiotic resistance profiles across different countries, consideration of HAP treatment should address broad principles applicable to the intensive care setting and leave the choice of specific antimicrobial agents to local experts based on their intelligence as to the local pathogen and susceptibility situation.28
It was suggested that a hierarchy of risk factors suitable for guiding HAP treatment decisions should be defined, with possible parameters including the presence of specific organisms [Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas, multidrug-resistant pathogens or Enterobacteriaceae], prior antibiotic treatment, underlying disease, immunosuppression, a history of travel, prior residence in healthcare facilities, time of HAP onset and local bacteriological epidemiology. There were considered to be two treatment approaches requiring assessment:
- Empirical treatment according to HAP severity and local antibiotic susceptibility, based on the ethos of giving appropriate antibiotic treatment early and at a clinically effective dose.
- Treatment based on the presence of risk factors, with patients having no obvious risk factors being treated for S. aureus and Enterobacteriaceae infection and those with risk factors undergoing additional treatment for Pseudomonas and MRSA.
Other important issues were the principles of treating patients with and without sepsis. Maintaining optimal blood sugar, haematocrit, ventilation and fluid control were also considered relevant. Following initiation of treatment, the optimal management of non-responding patients requires consideration as to the duration of therapy and use of appropriate antibiotic dose de-escalation regimens in responding patients.
HAP prevention guidelines would focus on issues specific to nosocomial pneumonia and would be classified according to whether the patient was ventilated or non-ventilated. Key areas for assessment were considered to be:
- Preventing aspiration using positional, secretion and subglottic secretion drainage strategies.
- Ventilator issues such as the frequency of circuit changes and the use of nebulizers, heated humidifiers and heat moisture exchangers.
- Oral versus nasal intubation.
- Antibiotic prophylaxis for VAP, considering short-term systemic and topical/oropharyngeal therapies, and SDD.
- Prevention of atelectasis using kinetic beds and physiotherapy.
- Oral care.
- Stress ulcer prophylaxis.
- Staff education.
- Hand hygiene.
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Pan-European HAP guidelines |
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Given the wealth of European country-specific recommendations already available and the comprehensive evidence assessment and synthesis documented during production of the UK HAP guidelines, the meeting participants considered it unnecessary to produce a set of pan-European guidelines from scratch. Instead having identified key areas of interest, pan-European guidelines should be developed to provide recommendations on aspects of HAP common to all treatment settings and locations and to reflect the differing perspectives of the countries involved. Principles to be followed during the pan-European HAP guideline development process are summarized in Table 3. The aim of pan-European guidelines should be to identify a common core of good clinical practice, supported by evidence that links processes of care to important clinical outcomes. This would be the starting point for the development of a care bundle, comprising interventions that independently affect patient mortality and morbidity.14
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Coordinated work on pan-European guidelines represents an ideal time to set priorities for new research by identifying controversies or important but previously unconsidered aspects of HAP. There are significant gaps in the evidence base for all areas of diagnosis, treatment and prevention. Specific diagnostic issues raised by meeting participants included the applicability of surveillance cultures and the use of scoring systems (such as the Clinical Pulmonary Infection Score) and biological disease markers (such as procalcitonin) in HAP diagnostic algorithms. Treatment issues included the role of linezolid, colistin and non-antibiotic treatment modalities; switching from intravenous to oral antibiotic regimens and optimal treatment duration. Considering aspects of HAP prevention, the impact of monitoring environmental contamination and the use of closed suctioning for respiratory tract secretions have been sparsely considered despite being important issues of current interest. In addition, there have been no attempts to prioritize HAP prevention measures to define those that result in optimal benefit.
On a more general level, there are no well-conducted pharmacoeconomic or health economic studies addressing the benefits of HAP diagnostic, treatment or prevention measures. This situation is not unique to HAP guidelines, with little evidence being available concerning the cost-effectiveness of guideline implementation in general.29 A key problem is that it is often impractical to measure clinical outcomes directly during a study of guideline implementation. Consequently, it is important that evidence is available linking recommended processes of care with clinical outcomes. Unfortunately, the few studies that have documented the cost of development and implementation of guidelines have focused on changes in processes that were supported by clinical judgement rather than research evidence. The creation of a pan-European HAP care bundle would provide an important platform for research on the cost-effectiveness of guideline implementation.
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Guideline implementation |
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It is recognized that without effective implementation, guideline production is meaningless. Defining evidence-based processes of care is an essential step in any implementation plan but research is only one component of evidence, with others comprising clinical experience and patient preferences.30 Moreover, evidence needs to be considered in terms of two equally important elements: the context into which the evidence is to be placed and the method by which the process is facilitated. According to this model of implementation, research evidence must be supported by high levels of consensus and consistency of view amongst professionals who work in partnership with patient representatives and organizations.
Key aspects of improving evidence quality, through the production of pan-European HAP guidelines, were discussed by the meeting participants and are summarized in Table 3. When considered in terms of the model for implementation, key elements for creating high-impact evidence include:
- Gaining acceptance of guideline recommendations from practitioners in all clinical disciplines concerned with treating HAP. Participation of all such treatment disciplines in guideline development is likely to promote widespread acceptance of the final recommendations.
- Gaining acceptance of guideline recommendations from all staff involved in treating patients with HAP. Suitable education packages are key to engendering an ethos of responsibility across all levels of hospital staff.
- Gaining endorsement for guideline recommendations at the national and institutional level and from bodies such as learned societies or the European Centre for Disease Prevention and Control would promote acceptance. The increasing public awareness and concern over levels of HAP are pushing governments to introduce guidance as to suitable standards of care.
- Validation of the guidelines is important and goes hand-in-hand with assessing their implementation.
The broad range of recommendations produced, as part of any HAP guidelines, is likely to confound implementation. Targeting a small number of simple, effective and robust core elements for universal adoption is likely to result in greater acceptance by professionals and patients and hence to promote improved standards of care.
Development of pan-European HAP guidelines is also an opportunity to improve the context for implementation by defining and testing measures for improvement.31 Studies have shown that auditing compliance with guideline recommendations and provision of feedback are important in optimizing benefit.32 Ideally, the development of suitable measures should occur in conjunction with guideline production and SIGN now requires that an implementation group is a core component of any guideline committee.27 A panel of suitable impact assessment tools is currently being considered by the UK HAP guideline development committee.
The meeting participants agreed that writing pan-European guidelines will create an excellent opportunity to start the process of identification and testing of measures for improvement. Undertaking this work in a pan-European context will significantly enhance the opportunities for supporting training, through the involvement of professional societies by incorporating their well-established educational resources.
Establishing a pan-European care bundle for HAP, with measures to test its implementation, will establish a solid basis for changing practice. Experience in the United States shows that collaborative implementation of key recommendations has had greater impact on VAP than might have been expected, from evidence on the effectiveness of individual processes of care components.14 A possible explanation is that when care processes are grouped into simple bundles, caregivers are more likely to implement them and make fundamental changes in procedures. According to this hypothesis, the format served to provoke the varied disciplines in the ICU to organize their work, adapt the delivery system and reliably implement the ventilator bundle. The adaptations included multi-disciplinary rounds, daily patient goals and the use of weaning protocols by respiratory therapists.14
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Conclusions |
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European country-specific HAP guidelines vary both in their coverage of different aspects of the disease and in their overall recommendations. The production of an overarching pan-European HAP guideline represents an opportunity to address controversies between existing recommendations and develop guidance on issues that have not previously been considered. Development of a pan-European consensus HAP guideline could provide broad recommendations covering aspects of HAP common to all treatment settings and locations, while reflecting the perspectives of the countries involved. Guidelines describing general principles could be readily adapted according to local antibiotic resistance patterns. However, before the process is initiated generic issues surrounding the methodology behind guideline development and implementation should be reviewed, in order to ensure that any output is rigorous and comprehensive.
A new comprehensive pan-European guideline should be viewed as an impetus for change to improve HAP care practices and requires the development of a suitable implementation strategy. One approach could be to target a small number of achievable key objectives for implementation that could be packaged into a care bundle.
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Transparency declarations |
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R. M. has received speaker honoraria from AstraZeneca and Wyeth; D. C. has received speaker honoraria from Wyeth, Merck, Pfizer, Cubist and Elan, and is on the Data Safety Monitoring Board for a new Johnson & Johnson cephalosporin antibiotic. He has received research support from Bard Pharmaceuticals and is on their FDA data submission consulting panel; J. R. has received speaker honoraria and/or research funding from Pfizer, Johnson & Johnson, Merck, Rhone-Poulenc, Kimberley-Clark, AstraZeneca, Able, Wyeth, Amgen and Bard. He is a member of Johnson & Johnson, Pfizer, Basilea, Arpida, Wyeth Pharmaceuticals, Novartis, and Intrabiotics advisory boards; M. S. has received speaker honoraria and/or research funding from Pfizer, Roche Diagnostics, Becton–Dickinson, Chiron-Novartis, Wyeth, AstraZeneca, Johnson & Johnson, GeneOhm and BioMérieux. He has served on advisory boards for Pfizer, Chiron-Novartis, Wyeth, Johnson & Johnson, GlaxoSmithKline and 3M and is a member of the GlaxoSmithKline-supported Belgian Sanford Guide Working Party on Antimicrobial Therapy and their Infectious Diseases Advisory Board; J. C. serves on the Nektar advisory board and has received speaker honoraria from Pfizer, AstraZeneca, Wyeth, Pharm-Olam, and Brahms; G. C. has received speaker honoraria from Pfizer and Glaxo-SmithKline; H. L. has received speaker honoraria research funding and/or consulting fees from Bayer, Pfizer, Sanofi-Aventis, Wyeth, Johnson & Johnson, Intermune, Daiichi and Astellas; H. G. has received speaker honoraria and/or research funding from Wyeth, GlaxoSmithKline, Pfizer, Merck and Sanofi-Aventis; M. J. M. B. has received speaker honoraria, research funding and/or consultancy fees from 3M, Intrabiotics, BioMerieux, Chiron, Pfizer, GeneOhm, Aventis and Novartis; P. D. has received speaker honoraria and/or research funding from Pfizer, Wyeth, GlaxoSmithKline and Boehringer Ingelheim and is a member of the Johnson & Johnson global anti-infective advisory board; A. O., N. F. M. and H. E. have no conflicts of interest to declare.
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Acknowledgements |
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The European HAP guideline consensus meeting was supported by Wyeth International.
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References |
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1 . Eriksen HM, Iversen BG, Aavitsland P. Prevalence of nosocomial infections and use of antibiotics in long-term care facilities in Norway, 2002 and 2003. J Hosp Infect (2004) 57:316–20.[CrossRef][Web of Science][Medline]
2 . Klavs I, Bufon Luznik T, Skerl M, et al. Prevalence of and risk factors for hospital-acquired infections in Slovenia-results of the first national survey, 2001. J Hosp Infect (2003) 54:149–57.[CrossRef][Web of Science][Medline]
3 . Lizioli A, Privitera G, Alliata E, et al. Prevalence of nosocomial infections in Italy: result from the Lombardy survey in 2000. J Hosp Infect (2003) 54:141–8.[CrossRef][Web of Science][Medline]
4 . Masterton R. The place of guidelines in hospital acquired pneumonia. J Hosp Infect (2007) [Epub ahead of print 4 May 2007].
5 . Gross P, Neu H, Aswapokee P, et al. Deaths from nosocomial infections: experience in a university hospital and a community hospital. Am J Med (1980) 68:219–23.[CrossRef][Web of Science][Medline]
6 . Vanhems P, Lepape A, Savey A, et al. Nosocomial pulmonary infection by antimicrobial-resistant bacteria of patients hospitalized in intensive care units: risk factors and survival. J Hosp Infect (2000) 45:98–106.[CrossRef][Web of Science][Medline]
7 . Fagon JY, Chastre J, Hance AJ, et al. Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med (1993) 94:281–8.[CrossRef][Web of Science][Medline]
8
.
Leu HS, Kaiser DL, Mori M, et al. Hospital-acquired pneumonia. Attributable mortality and morbidity. Am J Epidemiol (1989) 129:1258–67.
9 . Craven DE. Epidemiology of ventilator-associated pneumonia. Chest (2000) 117:186–7s.[CrossRef]
10 . Safdar N, Dezfulian C, Collard HR, et al. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med (2005) 33:2184–93.[CrossRef][Web of Science][Medline]
11
.
Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med (2002) 165:867–903.
12
.
American Thoracic Society and the Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med (2005) 171:388–416.
13 . Luna CM, Vujacich P, Niederman MS, et al. Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest (1997) 111:676–85.[Web of Science][Medline]
14 . Resar R, Pronovost P, Haraden C, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf (2005) 31:243–8.[Medline]
15 . British Society of Antimicrobial Chemotherapy. CONSULTATION: Draft Guidelines on Hospital Acquired Pneumonia. www.bsac.org.uk/latest_news.cfm?cit_id=511&FAArea1=customWidgets.content_view_1&usecache=false (13 March 2007, date last accessed).
16 . Lorenz J, Bodmann K-F, Bauer TT, et al. Nosokomiale pneumonie: prävention diagnostik und therapie. Pneumologie (2003) 57:532–45.[CrossRef][Medline]
17 . Rommes JH, Spronk PE, van der Voort PHJ, et al. Richtlijn het voorkomen van bacteriële longontsteking en sterfte tijdens beademing. www.nvic.nl/uploads/NVIC_richtlijn_longontsteking_definitieve_versie_naar_WVen__2_.pdf (13 March 2007, date last accessed).
18 . Jordà Marcos R, Torres Martí A, Ariza Cardenal FJ, et al. Recommendations for the treatment of severe nosocomial pneumonia. Arch Bronconeumol (2004) 40:518–33.[CrossRef][Web of Science][Medline]
19 . Ahrén C, Agvald-Ohman C. Healthcare-related pneumonia. In: Prevention of Healthcare-Related Infections (2006) Swedish National Board of Health. 179–94.
20 . Ministère de l'Emploi et de la Solidarité, Secrétariat d'Etat à la Santé et à l'action sociale Comité technique national des infections nosocomiales. 100 recommandations pour la surveillance et la prévention des infections nosocomiales. http://www.sante.gouv.fr/htm/pointsur/nosoco/guide/sommaire.html (13 March 2007, date last accessed).
21 . The Hellenic Diagnostic and Therapeutic Guidelines for Ventilation Associated Pneumonia. (2007) The Hellenic Tender for Disease Control and Prevention.
22 . Turkish Thoracic Society. Guidelines for diagnosis and therapy of hospital-acquired pneumonia 2002. 3(Suppl 4):1–13. http://www.toraks.org.tr/journal/text.php3?id=230 (13 March 2007, date last accessed).
23 . Medicin DK. Infomatum A/S. (2006) 974–6. ISBN 87-88835-14-6.
24 . Legrand JC, Colardyn F, Firre E, et al. Diagnostic et traitement antimicrobien des pneumopathies acquises au respirateur chez l'adulte. (2002) ISBN 90-805936-2-1 NUR 870.
25 . www.escmid.org/sites/index.aspx (13 March 2007, date last accessed).
26
.
Fervers B, Burgers JS, Haugh MC, et al. Adaptation of clinical guidelines: literature review and proposition for a framework and procedure. Int J Qual Health Care (2006) 18:167–76.
27 . SIGN 50: a guideline developers' handbook. Published February 2001, updated May 2004. www.sign.ac.uk/guidelines/fulltext/50/index.html (13 March 2007, date last accessed).
28 . Andriesse GI, Verhoef J. Nosocomial pneumonia: rationalizing the approach to empirical therapy. Treat Respir Med (2006) 5:11–30.[CrossRef][Medline]
29
.
Grimshaw J, McAuley LM, Bero LA, et al. Systematic reviews of the effectiveness of quality improvement strategies and programmes. Qual Saf Health Care (2003) 12:298–303.
30 . Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Saf Health Care (1998) 7:149–58.[Abstract]
31 . Solberg LI, Mosser G, McDonald S. The three faces of performance measurement: improvement, accountability, and research. Jt Comm J Qual Improv (1997) 23:135–47.[Medline]
32 . Cocanour CS, Peninger M, Domonoske BD, et al. Decreasing ventilator-associated pneumonia in a trauma ICU. J Trauma (2006) 61:122–30.[Web of Science][Medline]
33 . The AGREE Collaboration. Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument (2001) www.agreecollaboration.org (13 March 2007, date last accessed).
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