Journal of Infection (2012) 65, 285e291

www.elsevierhealth.com/journals/jinf

A European survey of nosocomial infection controland hospital-acquired pneumonia preventionpractices

Jean-Damien Ricard a,b,c,*, Giorgio Conti d, Maud Boucherie e,Christoph Hormann f, Jan Poelaert g, Michael Quintel h, Sten Rubertsson i,Antoni Torres j

aAP-HP, Hopital Louis Mourier, Service de Reanimation Medicale, Colombes, Franceb Institut National de la Sante et de la Recherche Medicale (INSERM) U722, 16 rue Henri Huchard, Paris F-75018, FrancecUniv Paris Diderot, Sorbonne Paris Cite, UMRS 722, F-75018 Paris, FrancedDepartment of Anesthesia and Intensive Care, Policlinico A. Gemelli, Rome, ItalyeClinical Research Department, Covidien, Elancourt, FrancefDepartment of Anesthesia and Intensive Care Medicine, University Hospital, Innsbruck, AustriagDepartment of Anesthesiology, Free University Hospital Brussels, Brussels, Belgiumh Emergency and Intensive Care Medicine, University of G€ottingen, G€ottingen, GermanyiDept. of Surgical Sciences/Anaesthesiology and Intensive Care, Uppsala University, SE 751 85 Uppsala, Swedenj Pulmonology and Critical Care Department, Hospital Clinic, Barcelone, Spain

Accepted 30 June 2012Available online 5 July 2012

KEYWORDSInfection control;Nosocomial infection;Cross contamination;Healthcare practices;Mechanical ventilation;Intensive care

* Corresponding author. Service defax: þ33 1 47 60 61 92.

E-mail address: jean-damien.ricar

0163-4453/$36 ª 2012 The British Infehttp://dx.doi.org/10.1016/j.jinf.2012

Summary Objectives: We aimed to examine organizational, structural and routine infectioncontrol measures provided by European ICUs and staff practices in ventilator-associatedpneumonia prevention in relation with current recommendations.Methods: European ICU staffs were invited to complete a web-based 20 closed-item question-naire.Results: 675 nurses and 886 physicians from 13 countries answered the questionnaire. Mediannumber of respondents per country was 118.0 (64.5e155.5). Availability and organizationalaspects of infection control revealed wide variations between countries. Among them,single-patient rooms was the aspect with the lowest availability (median availability 38%),but the largest variation ranging from 15 to 84%. Self-reported median adherence rate torecommendations was 72% (34.5e83.0) with a strong correlation between nurses and physi-cians responses (r2 Z 0.96; p < 0.0001). Sub-glottic drainage (31%), and infrequentventilatory-circuit change (24%) were the measures with the lowest adherence rate whereas

Reanimation Medicale, Hopital Louis Mourier, F_92700 Colombes, France. Tel.: þ33 1 47 60 67 50;

d@lmr.aphp.fr (J.-D. Ricard).

ction Association. Published by Elsevier Ltd. All rights reserved..06.016

286 J.-D. Ricard et al.

preferential use of oral intubation (90%) and of NIV (84%) and use of HMEs (82%) were the threewith the highest rate. Organization of infection control was consistently self-reported. Dispar-ities among countries were more frequent for specific actions regarding airway management,and even moreso for controversial issues (subglottic drainage, closed-suction systems).Conclusion: This European survey shows a 72% overall adherence rate to VAP prevention mea-sures; with strong agreements between physician and nurses but considerable differencesamong countries for availability and organization aspects of infection control, providinghealthcare authorities with figures for future programs.ª 2012 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Introduction

Despite numerous advances in its comprehension andprevention,1 ventilator-associated pneumonia (VAP)remains the most frequent nosocomial infection in theintensive care unit (ICU). It places a huge burden on bothpatient safety and healthcare services and resources.Patient safety is obviously affected because occurrence ofa nosocomial infection influences patient outcome withattributable morbidity and mortality. Healthcare costs areconsiderably increased because of prolonged stay2 andadditional use of healthcare resources to treat nosocomialinfections (antibiotics, isolation measurements, staff, etc).

Any nosocomial infection prevention and VAP in partic-ular, is an evolving and dynamic process that encompassesstructural, organisational, technical and medical aspects.Such diversity is not always addressed in recommendationsand guidelines that tend to focus on medical and technicalaspects, those addressed in clinical trials. Structural andorganisational aspects of nosocomial infection preventionare often overlooked in clinical trials because difficult toevaluate and modify. Nonetheless, they have been shownto affect care and patient outcome. Bloodstream infectionand cross-transmission of methicillin-resistant Staphylococ-cus aureus for example, may be prevented by the use ofsingle rooms.3 Understaffing is also a recurrent problem inICU that has been proved to increase NI4 but also lengthof mechanical ventilation in weaning of COPD patients.5

Numerous guidelines and recommendations on VAP andits prevention are available.6 Although these recommenda-tions encompass both pharmacological and non-pharmacological aspects, they do not take into accountcountry and ICU specificities. Selective digestive decontam-ination is an astute example of a VAP prevention measurethat is supported by strong evidence and that is paradoxi-cally not widely applied. Indeed, this practice is mostlyused in ICUs with very low rates of multidrug resistant bac-teria. Elsewhere in Europe, where prevalence of such mi-croorganisms is much higher, this practice is not oftenapplied. Data indicate an overall non-adherence rate of37.0% among intensive care unit practitioners regardingpublished recommendations for the VAP prevention.7

Among reasons for non-adherence, unavailability and costswere reasons often put forward. Because this studyinterviewed a very small number of physicians,7 we wereinterested in knowing on a much broader scale organiza-tional and structural nosocomial infection control measuresprovided in European ICUs, how ICU staff complied with VAPprevention practices, how these practices differed amongEuropean countries and if practices differed between

nurses and physician. Results of this study have beenpresented in part as an abstract.8

Methods

We elected to develop a simple, short, closed-endedquestionnaire using items appropriate for gathering dataon current practices regarding VAP prevention. A panel ofEuropean ICU physicians, interested in VAP prevention,developed a web-based questionnaire (http://www.vapaway.eu/newsflash/vapaway-questionnaire.html) toaddress the question of compliance to VAP preventionguidelines by ICU staff. The questionnaire was developedby extracting non-pharmacological (with the exception oforal rinse with chlorhexidine) aspects of VAP preventionfrom different guidelines, reviews, and consensus confer-ences. Preliminary questionnaires were developed duringdiscussions held by the investigators during panel meetings.Questionnaire was pre-tested and redundant or ambiguousitems were removed. Finally, both consensual and less con-sensual non-pharmacological aspects were assessedthrough 20 closed labeled questions, with dichotomousyes or no answers. Information regarding the questionnairewas provided via email push lists. Participants to ICUcongresses of national societies of intensive care were in-vited to answer the questionnaire on computers locatedin the exhibition hall.

Statistical analysis

Results are expressed as percentage of positive answers(i.e., adherence to recommendations) with median and25e75 percentiles. To ensure minimal representativeness,only those countries providing 30 respondents or more wereincluded in the analysis. Global (all countries together) andlocal (each country) agreement between nurses and physi-cians answers was performed by linear regression. A pvalue < 0.05 was considered significant.

Results

The website questionnaire was accessible worldwide during14 months (October 2007 through December 2008), periodduring which 2117 questionnaires were answered. Wereport here the 1561 (675 nurses and 886 physicians)answers coming from European ICU staff of 13 countries.Table 1 displays the numbers of questionnaires completedper country. There was a median of 118.0 (64.5e155.5)respondents per country, with 43.0 (16.0e75.5) nurses per

Table 1 Answers to questionnaire per country.

Country Total number of answers (n Z 1561) Nurses (n Z 675) Physicians (n Z 886)

Germany 299 170 129Austria 185 76 109Spain 177 103 74France 134 28 106Sweden 133 48 85Italy 125 14 111UK 118 45 73Portugal 95 75 20Greece 77 7 70Poland 65 36 29Switzerland 64 43 21Netherlands 55 18 37Belgium 34 12 22Median 118.0 (64.5e155.5) 43.0 (16.0e75.5) 73.0 (25.5e107.5)

Hospital-acquired pneumonia prevention in Europe 287

country and 73.0 (25.5e107.5) physicians. Rates for eachitem of the questionnaire are given in Table 2a and 2b.Because some items of the questionnaire are structure-dependent and address infection control in general weseparated them (Table 2a) from those that were moreteam-dependent and directed towards VAP prevention(Table 2b). Regarding the latter, median adherence ratewas 72% (34.5e83.0). There was a very good agreement be-tween nurses’ and physicians’ answers, as shown on Fig. 1

Table 2 (a) Availability and organizational aspects of infection

Single-patient roomsAlcohol-based hand rubs used routinelyAccess to hand washing pointsRoutine use of patient-care protocolsRoutine infection surveillanceInteraction with infection control teamPatients regularly screened for MDROa

Contact precaution used in case of MDROIsolation of patient with MDROPatient dedicated gowns & disposable gloves at each bedside

Prevention measures

Oral intubation vs nasal intubationUse of non invasive mechanical ventilationRegular check of cuff pressurePatients systematically placed semi-recumbentOral rinse with chlorhexidine performed routinelyClosed endotracheal suctioning used in patients carrying MDROSub-glottic drainage performed routinelyHMEsb used whenever possibleHMEs changed less frequently than 48 hVentilator circuits not changed routinely (only per patient)Median (25e75 percentile)a MDRO: multidrug resistant organisms.b HMEs: heat and moisture exchangers.

(r2 Z 0.96; p < 0.0001). This agreement was assessedlocally for each country and a similar, very good agreementwas found in every country (data not shown). Fig. 2 depictsanswers per country for each prevention measure. Amongstructural and organizational aspects of prevention, avail-ability of single patient rooms was the one the least com-plied with (38%) and hand hygiene policy (use of alcoholbased hand rubs and access to wash hand basin) the onethe most (both 94%). Among airway management aspects,

control, (b) Adherence to VAP prevention measures.

Availability/adherence (%)

All Nurses Physicians

34 38 3794 97 9194 96 9379 83 7684 87 8375 79 7374 78 7193 97 9083 88 7980 76 65

Adherence rate (%)All Nurses Physicians

90 89 9184 84 8381 87 7681 87 7748 49 4763 64 6231 32 3082 83 8138 34 4224 22 2572 (34.5e83)

0 25 50 75 1000

25

50

75

100

Nurses

Phy

sici

ans

r²=0.96 p<0.0001

Figure 1 Nurses’ and physicians’ compliance to the 20 ques-tions are displayed in Figure 1. Each circle represents a ques-tion. A strong, statistically significant correlation was foundbetween nurses and physicians answers to these questions.

288 J.-D. Ricard et al.

use of subglottic drainage and infrequent circuit changeswere the least complied with (respectively 31 and 24%),whilst oral intubation was the recommendation the mostcomplied with (90%).

Vast disparities were noticed among countries for somerecommendations. The greatest disparity was noted for theuse of single-patient rooms, ranging from less than 15%responders to up to 85%; whereas hand hygiene policy andpreferential use of HMEs were the most consensual mea-sures (Fig. 2).

Discussion

This is to date the largest questionnaire on VAP preventionever performed on European ICU staff. Main results can besummarized as follows:

- Overall adherence rate to recommendations was 72%,and nurses and physicians had very similar rates of ad-herence; providing a strong agreement between nursesand physicians attitude toward VAP prevention.

- If responders offered similar answers for organisationalaspects, compliance to structural aspects (singlepatient room noticeably) showed wide disparitiesamong countries.

- General airway management with respect to VAPprevention (preferential use of NIV, orotracheal intuba-tion, use of HMEs) received large agreement amongresponders, whereas more specific aspects (semirecum-bant position, subglottic drainage, closed system tra-cheal suctioning) showed wide disparities amongcountries.

These results have strong policy potential and implica-tion. First, they may help local infection control agencies toidentify more specifically which aspect they shouldconcentrate their efforts on. Second, European societiesand healthcare agencies may benefit from this picture oflocal practices to focus their communication and also todirect research.

Barriers to physician adherence to clinical practiceguidelines and recommendations have been extensively

studied in numerous fields.9 Regarding VAP prevention, Re-llo et al identified three main reasons for nonadherence :disagreement with interpretation of clinical trials; unavail-ability of resources; and costs.7 In the present study, theexistence of single patient rooms was the aspect of preven-tion that showed the greatest disparity among countries.Participants answer to this item very probably reflectsa state of fact, the choice of having single-patient roomshaving been driven at the time of the hospital’s construc-tion by architectural, technical, economical and medicalreasons. Nonetheless, this disparity may be consistentwith disparate attitudes towards screening for and isolationof patients with MDRO and these aspects have been a mat-ter of debate, noticeably with the dealing with MRSA pa-tients. Although still a matter of debate, recent studieshave shown the beneficial effect of single patient roomsto prevent nosocomial bloodstream infection and cross-transmission of methicillin-resistant S. aureus3 or to over-come a Glycopeptid- intermediate S. aureus (GISA)epidemics.10 This aspect may be even more prominent inthe coming years with the spread and dissemination ofnew extended spectrum of betalactamase.11 Adherenceto basic hygiene recommendations such as hand washingwith alcohol-based solutions was high, in agreement withthe current knowledge that the practicality of this measurehas contributed to increase hand hygiene compliance in theICU12 where studies have shown that it is difficult to obtain.

In agreement with previous surveys,13 most responderspreferred oral intubation and agreed on favoring NIV when-ever possible. Despite some debate on the applicability ofthe semirecumbent position,14 responders (including Dutchresponders) largely adhered to this recommendation, whichis present in most guidelines and recommendations. Sur-prisingly, less than half the responders declared performingregular oral rinse with chlorhexidine, despite a recent met-analysis indicating its beneficial effect in VAP prevention.15

Potential confusion surrounding the different techniquesavailable (oral decontamination with antibiotics16 or withantiseptics) and the best regimen (chlorhexidine (with17

or without colistin) at 0.12, 0.2 or 2%)) may explain this re-sult. Our 48% adherence rate to oral rinse with chlorhexi-dine is e even if slightly lower e consistent with the 61%rate found by Rello et al. during a survey of ICU practices18

although considerable disparity was seen between coun-tries, ranging from 25 to 85% (Fig. 2).

As indicated above, subglottic secretion drainage wasone of the measures least adhered to. Uncertain benefit ofthis measure regarding late onset VAP prevention mayexplain this result. One can expect that the recentpublications showing a significant reduction of late onsetVAP with this technique19 might change this figure in thenear future. Use of closed suction systems was among themeasures showing the widest range of adherence rates,from over 90% in the UK to less than 30% in Spain. Althoughtwo recent meta-analysis of studies evaluating this devicefailed to show any benefit in terms of VAP reduction20,21

one meta-analysis hypothesized that closed suction systemscould be profitable to reduce risk of cross contamination,especially in case of MDRO.20 This aspect was investigatedin a recent study that compared open and closed suctioningand showed that use of closed suction system significantlyreduced bacterial contamination of healthcare workers

Figure 2 Adherence rate of each country to each of the 20 items of the questionnaire. The doted line represents the median rateof the 13 countries. Each number on the X-axis has its corresponding item of the questionnaire in the Table.

Hospital-acquired pneumonia prevention in Europe 289

hand and endotracheal tube equipment22 suggesting thatthese devices should be use as part of more general mea-sures to reduce risk of cross contamination.

Finally, preferential use of HMEs was widely adhered to,despite the fact that studies have consistently found thattheir use did not affect VAP rate23; even if they are much

easier to use, reduce cost, protect circuit contaminationand reduce risk of cross-contamination.24 Interestingly,and despite ample and consistent evidence that durationof their use can be prolonged for up to a week,25 few re-sponders declared changing them less frequently than48 h. This was also the case for infrequent changes of

290 J.-D. Ricard et al.

ventilator circuits, for which studies have consistentlyshown that circuits do not need to be changed so often (apivotal study26 even showed that they needed not bechanged during the entire duration of ventilation of a givenpatient). Despite this, our results indicate that ICUscontinue to change them more frequently.

A number of recommendations and guidelines on VAPprevention have been issued recently, including one froma European Task Force.6 Their direct impact on routine careis difficult to evaluate, although studies have found in thepast that published recommendations did not appear tosubstantially affect the use of such prevention interven-tions within individual intensive care units.25

Previous surveys on ICU nurses and RT,27 and on ICU physi-cians7 found that the degree of nonadherence seemed to beindependent of the strength of the evidence in support ofspecific interventions. On the contrary, we found that mea-sures with weaker evidence were the ones for which levelof adherence was smaller. This was particularly true for air-way management with one noticeable exception regardingrate of respiratory circuit change as discussed above.

Strength and limitations of the study

One can legitimately question the appropriateness ofmixing structural and practice items in the questionnaire.Answers to the former are obviously independent from therespondents practice. They do provide however a (albeitimperfect) picture of how ICUs are organized in Europe interms of infection control. There are indeed hints for theexternal validity of our findings. For example, Hansen et alreport a ratio of 8 single-patient rooms over 10 in Frenchparticipating ICUs to a European survey on MRSA infectioncontrol measures.28 We believe this ratio is consistent withthe 70% adherence rate of French responders in our surveyregarding the availability of single-patient rooms. Figuresare similarly consistent between the two studies for othercountries like Spain or Germany. Another obvious limitationto the study resides in its design, i.e., a closed item ques-tionnaire, with limited control on answers. Thus in some in-stances, they may reflect the responder’s opinion ratherthan his/her practice. This has been identified in otherfields, known as attitude e behaviour discrepancy and cog-nitive dissonance.29,30 One way to overcome this bias is byproviding validity and consistency to the answers.31 Thevery good agreement found between nurses’ and physi-cians’ answers for each country gives credit to their valid-ity. There was no control on responders understanding ofthe items, and misunderstanding or misinterpretation ofan individual item on the survey cannot be excluded.However, the very large number of responders may limitthis risk. A unique feature of our study lies in the unprece-dented number of responders coming from a large repre-sentation of European countries, although we were notable to provide a denominator so as to precise the relativerepresentation of each country. Such a study is the first ofits kind. Contrary to previous studies, the questionnairecomprised questions regarding organizational andstructural items, in addition to questions on routine care,both of which are fundamental to VAP prevention. The

combination of nurses and physicians in the study popula-tion provides a more accurate and realistic picture ofwhat is done in European ICUs. Indeed, nurses spend sub-stantially more time at the patients’ bedside than physi-cians. Any survey or audit on prevention that does notlook into their practices is necessarily biased, especiallyas recent studies underline insufficient knowledge on VAPprevention.32

Conclusion

This survey provides for the first time a picture of VAPprevention practices in Europe. Although the overall rate ofadherence was high (72%), important disparities were notedamong measures but also among countries. The detailedanalysis of these differences offers opportunities forimprovement per country and indicates direction of re-search and implementation programs for healthcareauthorities.

Authors’ contribution

JDR, GC, CH, JP, MQ, SR, AT designed the study, establishedthe questionnaire and tested it.

JDR and MB analyzed the data; and JDR, GC, CH, JP, MQ,SR, AT interpreted the data.

JDR drafted the manuscript and GC, CH, JP, MQ, SR, ATprovided substantial scientific input to the manuscript. Allauthors approved the final version of the manuscript.

Funding of the study

The study was funded by an unrestricted educational grantfrom Covidien. JDR, on behalf of all authors declares havinghad full access to the data and that the sponsor had noinvolvement in the study design, interpretation of the data,writing of the report, nor in the decision to submit thepaper for publication.

Conflict of interest

All authors (except MB) have received funding for speaking,advisory board membership and travel from Covidien. MB isemployed by Covidien.

Acknowledgements

None.

References

1. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am JRespir Crit Care Med 2002;165:867e903.

2. Markowicz P, Wolff M, Djedaini K, Cohen Y, Chastre J,Delclaux C, et al. Multicenter prospective study of ventilator-associated pneumonia during acute respiratory distress syn-drome. Incidence, prognosis, and risk factors. ARDS StudyGroup. Am J Respir Crit Care Med 2000;161:1942e8.

Hospital-acquired pneumonia prevention in Europe 291

3. Bracco D, Dubois MJ, Bouali R, Eggimann P. Single rooms mayhelp to prevent nosocomial bloodstream infection and cross-transmission of methicillin-resistant Staphylococcus aureus inintensive care units. Intensive Care Med 2007;33:836e40.

4. Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. Therole of understaffing in central venous catheter-associatedbloodstream infections. Infect Control Hosp Epidemiol 1996;17:150e8.

5. Thorens J-BMD, Kaelin RMMD, Jolliet PMD, Chevrolet J-CMD. In-fluence of the quality of nursing on the duration of weaningfrom mechanical ventilation in patients with chronic obstruc-tive pulmonary disease. Crit Care Med November 1995;23:1807e15.

6. Torres A, Ewig S, Lode H, Carlet J. Defining, treating and pre-venting hospital acquired pneumonia: European perspective.Intensive Care Med 2009;35:9e29.

7. Rello J, Lorente C, Bodi M, Diaz E, Ricart M, Kollef MH. Why dophysicians not follow evidence-based guidelines for preventingventilator-associated pneumonia?: a survey based on the opin-ions of an international panel of intensivists. Chest 2002;122:656e61.

8. Ricard JD, Conti G, Boucherie M, Hormann C, Poelaert J,Quintel M, et al. Vapaway project: a european audit of vap pre-vention practices. Intensive Care Med 2008;34:S36.

9. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud P-AC, et al. Why Don’t physicians follow clinical practice guide-lines?: a framework for improvement. JAMA 1999;282:1458e65.

10. de Lassence A, Hidri N, Timsit JF, Joly-Guillou ML, Thiery G,Boyer A, et al. Control and outcome of a large outbreak of col-onization and infection with glycopeptide-intermediate Staph-ylococcus aureus in an intensive care unit. Clin Infect Dis 2006;42:170e8. Epub 2005 Dec 13.

11. Kumarasamy KK, Toleman MA, Walsh TR, Bagaria J, Butt F,Balakrishnan R, et al. Emergence of a new antibiotic resistancemechanism in India, Pakistan, and the UK: a molecular, biolog-ical, and epidemiological study. Lancet Infect Dis 2010;2010:10.

12. Maury E, Alzieu M, Baudel JL, Haram N, Barbut F, Guidet B,et al. Availability of an alcohol solution can improve hand dis-infection compliance in an intensive care unit. Am J Respir CritCare Med 2000;162:324e7.

13. Esteban A, Anzueto A, Frutos F, Alia I, Brochard L, Stewart TE,et al. Characteristics and outcomes in adult patients receivingmechanical ventilation: a 28-day international study. Jama2002;287:345e55.

14. van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH,Joore HC, van Schijndel RJ, van der Tweel I, et al. Feasibilityand effects of the semirecumbent position to preventventilator-associated pneumonia: a randomized study. CritCare Med 2006;34:396e402.

15. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontaminationfor prevention of pneumonia in mechanically ventilated adults:systematic review and meta-analysis. Bmj 2007;334:889. Epub2007 Mar 26.

16. de Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF,van der Werf TS, et al. Decontamination of the digestive tractand oropharynx in ICU patients. N Engl J Med 2009;360:20e31.

17. Koeman M, van der Ven AJ, Hak E, Joore HC, Kaasjager K, deSmet AG, et al. Oral decontamination with chlorhexidine re-duces the incidence of ventilator-associated pneumonia. AmJ Respir Crit Care Med 2006;173:1348e55. Epub 2006 Apr 7.

18. Rello J, Koulenti D, Blot S, Sierra R, Diaz E, DeWaele JJ, et al. Oralcare practices in intensive care units: a surveyof 59 European ICUs.Intensive Care Med 2007;33:1066e70. Epub 2007 Mar 24.

19. Lacherade JC, De Jonghe B, Guezennec P, Debbat K, Hayon J,Monsel A, et al. Intermittent subglottic secretion drainage andventilator-associated pneumonia: a multicenter trial. Am J Re-spir Crit Care Med 2010;182:910e7.

20. Vonberg RP, Eckmanns T, Welte T, Gastmeier P. Impact of thesuctioning system (open vs. closed) on the incidence ofventilation-associated pneumonia: meta-analysis of random-ized controlled trials. Intensive Care Med 2006;32:1329e35.Epub 2006 Jun 21.

21. Jongerden IP, Rovers MM, Grypdonck MH, Bonten MJ. Open andclosed endotracheal suction systems in mechanically venti-lated intensive care patients: a meta-analysis. Crit Care Med2007;35:260e70.

22. Ricard JD, Eveillard M, Martin Y, Barnaud G, Branger C,Dreyfuss D. Influence of tracheal suctioning systems on healthcare workers gloves and equipment contamination: a compari-son of closed and open systems. Am J Infect Control 2011;39(7):605e7. Epub 2011 Apr 21.

23. Ricard JD, Boyer A, Dreyfuss D. The effect of humidification onthe incidence of ventilator-associated pneumonia. Respir CareClin N Am 2006;12:263e73.

24. Lorente L, Blot S, Rello J. New issues and Controversies in theprevention of ventilator-associated pneumonia. Am J RespirCrit Care Med 2010;2010:6.

25. Cook D, Ricard JD, Reeve B, Randall J, Wigg M, Brochard L,et al. Ventilator circuit and secretion management strategies:a Franco-Canadian survey. Crit Care Med 2000;28:3547e54.

26. Dreyfuss D, Djedaini K, Weber P, Brun P, Lanore JJ, Rahmani J,et al. Prospective study of nosocomial pneumonia and of pa-tient and circuit colonization during mechanical ventilationwith circuit changes every 48 hours versus no change. AmRev Respir Dis 1991;143:738e43.

27. Kaynar AM, Mathew JJ, Hudlin MM, Gingras DJ, Ritz RH,Jackson MR, et al. Attitudes of respiratory therapists andnurses about measures to prevent ventilator-associated pneu-monia: a multicenter, cross-sectional survey study. RespirCare 2007;52:1687e94.

28. Hansen S, Schwab F, Asensio A, Carsauw H, Heczko P, Klavs I,et al. Methicillin-resistant Staphylococcus aureus (MRSA) in Eu-rope: which infection control measures are taken? Infection2010;38:159e64.

29. LaPiere R. Attitudes vs actions. Soc Forces 1934;13:203e37.30. Pager D, Quillian L. Walking the talk? What employers say ver-

sus what they do. Am Sociol Rev 2005;70:355e80.31. Bertrand M, Mullainathan S. Do people mean what they say? Im-

plications for subjective survey data. Am Econom Rev 2001;91:67e72.

32. Llaurado M, Labeau S, Vandijck D, Rello J, Rosa A, Riera A,et al. Southern european intensive care nurses’ knowledge ofevidence-based guidelines for preventing ventilator-associated pneumonia. Med Intensiva 2011;35:6e12.