Intensive Care Medicine

, Volume 36, Issue 5, pp 773–780 | Cite as

A European care bundle for prevention of ventilator-associated pneumonia

  • Jordi Rello
  • Hartmut Lode
  • Giuseppe Cornaglia
  • Robert Masterton
  • The VAP Care Bundle Contributors



One recent approach to facilitating guideline implementation involves the use of care bundles.


This document presents a care bundle package addressing VAP prevention in an attempt to promote guideline-compliant practices. Uniquely, the development of these care bundles used a formalised methodology to assess the supporting data, based on multi-criteria decision analysis.


The resulting VAP care bundles for prevention were: non-ventilatory circuit changes unless specifically indicated, alcohol hand hygiene, appropriately educated and trained staff, incorporation of sedation control and weaning protocols into patient care, and oral care with clorhexidine.


Adoption of these care bundles should rationalise VAP prevention practises and improve outcomes, such as length of stay.


Ventilator-associated pneumonia Care bundles Prevention 



Ventilator-associated pneumonia


Feeding analgesia sedation thromboembolic ulcer glucose


Intensive care medicine


Hospital-acquired pneumonia


Multi-criteria decision analysis


Clinical Pulmonary Infection Score


American Thoracic Society


Infectious Disease Society of America


British Society for Antimicrobial Chemotherapy


Society of Healthcare Epidemiologists of America



The European VAP care bundle meetings were supported by an unrestricted grant from Wyeth International. Dr Rello's contribution is supported in part by a grant from Instituto Salut Carlos III (FISS 06/0060). Wyeth International had no control over and did not comment on the study design or the methods chosen, analysis of results, interpretation of findings or drafting the paper. One representative attended, observing and listening, without participating in the investigators’ discussions. We thank J. Eastgate for assisting with manuscript preparation of the first draft of the manuscript. J. Eastgate received compensation from Wyeth International. A. Pares (Tarragona, Spain) assisted with the final draft of the manuscript. She is funded by CIBERes.

Conflicts of interest statements

RM has received speaker honoraria from Astra Zeneca and Wyeth; JR has received speaker honoraria and/or research funding from Pfizer, Johnson & Johnson, Merck, Astra Zeneca and Wyeth. He is a member of the advisory boards of Johnson & Johnson, Pfizer and Wyeth Pharmaceuticals; MS has received speaker honoraria and/or research funding from Pfizer, Roche Diagnostics, Becton-Dickinson, Chiron-Novartis, Wyeth, Astra Zeneca, Johnson & Johnson, GeneOhm and BioMérieux. He has served on advisory boards for Pfizer, Chiron-Novartis, Wyeth, Johnson & Johnson, Glaxo-SmithKline and 3M, and is a member of the Glaxo-SmithKline-supported Belgian Sanford Guide Working Party on Antimicrobial Therapy and their Infectious Diseases Advisory Board; JC serves on the Nektar advisory board and has received speaker honoraria from Pfizer, Astra Zeneca, Wyeth, Pharm-Olam, and Brahms; GC has received speaker honoraria from Pfizer, Wyeth, Merck and Glaxo-SmithKline; HL has received speaker honoraria research funding and/or consulting fees from Bayer, Pfizer, Sanofi-Aventis, Wyeth, Johnson & Johnson, Intermune, and Daiichi and Astellas; HG has received speaker honoraria and/or research funding from Wyeth, Glaxo-SmithKline, Pfizer, Merck and Sanofi-Aventis; PD has received speaker honoraria and/or research funding from Pfizer, Wyeth, Glaxo-SmithKline and Boehringer Ingelheim, and is a member of the Johnson & Johnson global anti-infective advisory board; AO, HE, DC and KD have no conflicts of interest to declare. This study, including working meetings and secretarial assistance, was supported by an unrestricted grant from Wyeth International.

Supplementary material

134_2010_1841_MOESM1_ESM.doc (32 kb)
Supplementary material 1 (DOC 32 kb)


  1. 1.
    Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903PubMedGoogle Scholar
  2. 2.
    Grossman RF, Fein A (2000) Evidence-based assessment of diagnostic tests for ventilator-associated pneumonia. Chest 117(4 supp 2):177S–181SCrossRefPubMedGoogle Scholar
  3. 3.
    Safdar N, Dezfulian C, Collard HR, Saint S (2005) Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 33:2184–2193CrossRefPubMedGoogle Scholar
  4. 4.
    Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH, VAP Outcomes Scientific Advisory Group (2002) Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 122:2115–2121CrossRefPubMedGoogle Scholar
  5. 5.
    Fulbrook P, Mooney S (2003) Care bundles in critical care: a practical approach to evidence-based practice. Nurs Crit Care 8:249–255CrossRefPubMedGoogle Scholar
  6. 6.
    Cinel I, Dellinger RP (2006) Guidelines for severe infections: are they useful? Curr Opin Crit Care 12:483–488CrossRefPubMedGoogle Scholar
  7. 7.
    Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C (2006) An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 355:2725–2732CrossRefPubMedGoogle Scholar
  8. 8.
    Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T (2005) Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 31:243–248PubMedGoogle Scholar
  9. 9.
    Crunden E, Boyce C, Woodman H, Bray B (2005) An evaluation of the impact of the ventilator care bundle. Nurs Crit Care 10:242–246CrossRefPubMedGoogle Scholar
  10. 10.
    Burger CD, Resar RK (2006) “Ventilator bundle” approach to prevention of ventilator-associated pneumonia. Mayo Clin Proc 81:849–850CrossRefPubMedGoogle Scholar
  11. 11.
    Fox MY (2006) Toward a zero VAP rate: personal and team approaches in the ICU. Crit Care Nurs Q 29:108–114PubMedGoogle Scholar
  12. 12.
    Lai KK, Baker SP, Fontecchio SA (2003) Impact of a program of intensive surveillance and interventions targeting ventilated patients in the reduction of ventilator-associated pneumonia and its cost-effectiveness. Infect Control Hosp Epidemiol 24:859–863CrossRefPubMedGoogle Scholar
  13. 13.
    Laux L, Herbert C (2006) Decreasing ventilator-associated pneumonia: getting on board. Crit Care Nurs Q 29:253–258PubMedGoogle Scholar
  14. 14.
    Masterton R, Craven D, Rello J, Struelens M, Frimodt-Moller N, Chastre J, Ortqvist A, Cornaglia G, Lode H, Giamarellou H, Bonten MJ, Eraksoy H, Davey P (2007) Hospital-acquired pneumonia guidelines in Europe: a review of their status and future development. J Antimicrob Chemother 60:206–213CrossRefPubMedGoogle Scholar
  15. 15.
    Belton V, Stewart TJ (2002) Multiple criteria decision analysis: an integrated approach. Kluwer, BostonGoogle Scholar
  16. 16.
    Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, Canadian Critical Care Trials Group, Canadian Critical Care Society (2004) Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 141:305–313PubMedGoogle Scholar
  17. 17.
    Kollef MH, Shapiro SD, Fraser VJ, Silver P, Murphy DM, Trovillion E, Hearns ML, Richards RD, Cracchilo L, Hossin L (1995) Mechanical ventilation with or without 7-day circuit changes. A randomized controlled trial. Ann Intern Med 123:168–174PubMedGoogle Scholar
  18. 18.
    Long MN, Wickstrom G, Grimes A, Benton CF, Belcher B, Stamm AM (1996) Prospective, randomized study of ventilator-associated pneumonia in patients with one versus three ventilator circuit changes per week. Infect Control Hosp Epidemiol 17:14–19CrossRefPubMedGoogle Scholar
  19. 19.
    Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, Society for Healthcare Epidemiology of America, Association for Professionals in Infection Control, Infectious Diseases Society of America, Hand Hygiene Task Force (2002) Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 23:S3–S40CrossRefPubMedGoogle Scholar
  20. 20.
    Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, Perneger TV (2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 356:1307–1312CrossRefPubMedGoogle Scholar
  21. 21.
    Adams BG, Marrie TJ (1982) Hand carriage of aerobic Gram-negative rods by health care personnel. J Hyg (Lond) 89:23–31Google Scholar
  22. 22.
    Adams BG, Marrie TJ (1982) Hand carriage of aerobic gram-negative rods may not be transient. J Hyg (Lond) 89:33–46Google Scholar
  23. 23.
    Doebbeling BN, Pfaller MA, Houston AK, Wenzel RP (1988) Removal of nosocomial pathogens from the contaminated glove. Implications for glove reuse and handwashing. Ann Intern Med 109:394–398PubMedGoogle Scholar
  24. 24.
    Salahuddin N, Zafar A, Sukhyani L, Rahim S, Noor MF, Hussain K, Siddiqui S, Islam M, Husain SJ (2004) Reducing ventilator-associated pneumonia rates through a staff education programme. J Hosp Infect 57:223–227CrossRefPubMedGoogle Scholar
  25. 25.
    Zack JE, Garrison T, Trovillion E, Clinkscale D, Coopersmith CM, Fraser VJ, Kollef MH (2002) Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med 30:2407–2412CrossRefPubMedGoogle Scholar
  26. 26.
    Baxter AD, Allan J, Bedard J, Malone-Tucker S, Slivar S, Langill M, Perreault M, Jansen O (2005) Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia. Can J Anaesth 52:535–541CrossRefPubMedGoogle Scholar
  27. 27.
    Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K (2002) Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 346:1715–1722CrossRefPubMedGoogle Scholar
  28. 28.
    Kress JP, Pohlman AS, O’Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477CrossRefPubMedGoogle Scholar
  29. 29.
    Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M (2000) Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest 118:459–467CrossRefPubMedGoogle Scholar
  30. 30.
    Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, Kollef MH (1999) Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 27:2609–2615CrossRefPubMedGoogle Scholar
  31. 31.
    DeRiso AJ II, Ladowski JS, Dillon TA, Justice JW, Peterson AC (1996) Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest 109:1556–1561CrossRefPubMedGoogle Scholar
  32. 32.
    Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, Okamoto H, Hoshiba K, Ihara S, Yanagisawa S, Ariumi S, Morita T, Mizuno Y, Ohsawa T, Akagawa Y, Hashimoto K, Sasaki H (2002) Oral Care Working Group. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 50:430–433CrossRefPubMedGoogle Scholar
  33. 33.
    Pittet D, Boyce JM (2003) Revolutionising hand hygiene in health-care settings: guidelines revisited. Lancet Infect Dis 3:269–270CrossRefPubMedGoogle Scholar
  34. 34.
    Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW, Barrett S, Davey P, Harper P, Loveday C, McDougall C, Mulhall A, Privett S, Smales C, Taylor L, Weller B, Wilcox M; Department of Health (England) (2001) The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: guidelines for preventing hospital-acquired infections. Department of Health (England). J Hosp Infect 47(suppl):S3–S82Google Scholar
  35. 35.
    Garner JS (1996) Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 17:53–80CrossRefPubMedGoogle Scholar
  36. 36.
    Masterton RG, Galloway A, French G, Street M, Armstrong J, Brown E, Cleverley J, Dilworth P, Fry C, Gascoigne AD, Knox A, Nathwani D, Spencer R, Wilcox M (2008) Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 62:5–34CrossRefPubMedGoogle Scholar
  37. 37.
    American Thoracic Society (2005) Guidelines for the management of adults with hospital acquired, ventilator-associated, and healthcare-assisted pneumonia. Am J Respir Crit Care Med 171:388–416CrossRefGoogle Scholar
  38. 38.
    Richens Y, Rycroft-Malone J, Morrell C (2004) Getting guidelines into practice: a literature review. Nursing Standard 18:33–37Google Scholar
  39. 39.
    Cocanour CS, Peninger M, Domonoske BD, Li T, Wright B, Valdivia A, Luther KM (2006) Decreasing ventilator-associated pneumonia in a trauma ICU. J Trauma 61:122–129CrossRefPubMedGoogle Scholar
  40. 40.
    Rosenthal VD, Guzman S, Crnich C (2006) Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals. Am J Infect Control 34:58–63CrossRefPubMedGoogle Scholar
  41. 41.
    Misset B, Timsit JF, Dumay MF, Garrouste M, Chalfine A, Flouriot I, Goldstein F, Carlet J (2004) A continuous quality-improvement program reduces nosocomial infection rates in the ICU. Intensive Care Med 30:395–400CrossRefPubMedGoogle Scholar
  42. 42.
    Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR, Edwards J, Cho TW, Wittlake WA (2007) Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 35:1105–1112CrossRefPubMedGoogle Scholar
  43. 43.
    Fong JJ, Cecere K, Unterborn J, Garpestad E, Klee M, Devlin JW (2007) Factors influencing variability in compliance rates and clinical outcomes among three different severe sepsis bundles. Ann Pharmacother 41:929–936CrossRefPubMedGoogle Scholar
  44. 44.
    Zilberberg MD, Shorr AF, Kollef MH (2009) Implementing quality improvements in the intensive care unit. Ventilator bundle as an example. Crit Care Med 37:305–309CrossRefPubMedGoogle Scholar
  45. 45.
    Coffin SE, Komplas K, Classen D, Arias KM, Podgorny K, Anderson DJ, Busrstin H, Carfee DP, Dubberke DE, Fraser V, Gerdin DN, Griffin FA, Gross P, Kaye KS, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS (2008) Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 29:S31–S40CrossRefPubMedGoogle Scholar
  46. 46.
    Masterton RG (2009) Sepsis care bundles and clinicians. Intensive Care Med 35:1149–1151CrossRefPubMedGoogle Scholar
  47. 47.
    Hawe CS, Ellis KS, Cairns CJS, Longmate A (2009) Reduction of ventilator-associated pneumonia: active versus passive guideline implementation. Intensive Care Med 35:1180–1186CrossRefPubMedGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2010

Authors and Affiliations

  • Jordi Rello
    • 1
    • 5
  • Hartmut Lode
    • 2
  • Giuseppe Cornaglia
    • 3
  • Robert Masterton
    • 4
  • The VAP Care Bundle Contributors
  1. 1.Critical Care DepartmentVall d’Hebrón University Hospital, Institut de Recerca Vall d’Hebrón-UAB, CIBERESBarcelonaSpain
  2. 2.Department of Chest and Infectious Diseases, Heliosklinikum Emil van BehringAcademic Teaching Hospital of ChariteBerlinGermany
  3. 3.Department of PathologyUniversity of VeronaVeronaItaly
  4. 4.Ayrshire and Arran National Health Service Board the Ayr HospitalGlasgowUK
  5. 5.Critical Care Department, Vall d’Hebrón University HospitalBarcelonaSpain

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