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Intervention ATS/ISDA([FOOTNOTE=American Thoracic Society, 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(4):388-416.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805217]) CDC/ HICPAC([FOOTNOTE=Guidelines for preventing health-care-associated pneumonia, 2003 recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Respir Care. 2004;49(8):926-939.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=727209])
 CCCS/ CCCTG([FOOTNOTE=Dodek P, Keenan S, Cook D, et al; Canadian Critical Care Trials Group; Canadian Critical Care Society. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004;141(4):305-313.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805216]) AHRQ([FOOTNOTE=Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ). 2001;(43):i-x, 1-668.],[ANCHOR=],[LINK=])
 IHI([FOOTNOTE=Prevent Ventilator-Associated Pneumonia. Institute for Healthcare Improvement. 100,000 Lives Campaign. Available at:http://www.ihi.org/topics/VAP/Pages/default.aspx.],[ANCHOR=],[LINK=])
 AACN([FOOTNOTE=American Association of Critical Care Nurses. Practice Alert: Ventilator Associated Pneumonia. January 2008. http://www.aacn.org/clinical-resources/practice-alerts/ventilator-associated-pneumonia-vap.],[ANCHOR=],[LINK=]) SHN([FOOTNOTE=Safer Healthcare Now! Campaign April 2009 How-to Guide: Prevention of VAP. Available at:http://www.patientsafetyinstitute.ca/en/Topic/Pages/Ventilator-Associated-Pneumonia-(VAP).aspx?k=Ventilator-Associated%20Pneumonia%20(VAP) . Accessed October 21, 2013.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805209])
Continuous aspiration of subglottic secretions I II x(Consider) x   VI x
Enteral nutrition preferred to parenteral II UNRESOLVED ISSUE         xx
Maintain endotracheal cuff pressures >20 cm H2O II            
Oral preferred to nasal gastric tube placement II            
Oral preferred to nasal intubation II IB

 x       x
Recommendation for closed suction or single-use open suction   No Preference Closed Suction Recommended        
Intervention ATS/ISDA CDC/ HICPAC
 CCCS/ CCCTG AHRQ
 IHI
 AACN SHN
Appropriate hand disinfection

 I 1A         x
Contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or inline medication nebulizers II IB          
Develop and implement a comprehensive oral-hygiene program (which might include the use of an antiseptic agent) for patients in acute-care settings or residents in long-term care facilities at high risk of developing healthcare-associated pneumonia   II     x   x
Do not routinely change the patient’s ventilator circuit based on duration of use   IA x     VI  
Modulation of oropharyngeal colonization by the use of oral chlorhexidine Not Recommended UNRESOLVED ISSUE     x   x
Passive humidifiers or heat-moisture exchangers Unresolved UNRESOLVED ISSUE x        
Routine use of selective digestive decontamination Not Recommended UNRESOLVED ISSUE   x      
Semirecumbent positioning I II x x x VI x
Stress bleeding prophylaxis with either H2 antagonists or sucralfate Either UNRESOLVED ISSUE Sucralfate not recommended H2antagonists H2antagonists preferred/ consider PPIs    
Intervention ATS/ISDA CDC/HICPAC CCCS/ CCCTG AHRQ IHI AACN SHN
   
   
   
Avoid intubation and reintubation when possible I II          
Deep venous thrombosis (DVT) prophylaxis         x   x
Kinetic beds     x(Consider)        
Maintaining adequate staffing levels in the ICU II            
Noninvasive ventilation when possible I II          
Practices that promote patient mobility and autonomy

             x
Reduce duration of intubation and mechanical ventilation through protocols to improve the use of sedation and to accelerate weaning II       x   x
Staff education and involvement I 1A     x   x
Surveillance of ICU infections II 1B     x    
Tight glycemic control

 I            
ATS/IDSA Guidelines
Evidence Level Definition
Level I (high) Evidence comes from well-conducted, randomized controlled trials.
Level II (moderate) Evidence comes from well-designed, controlled trials without randomization or large case series with systematic analysis of disease patterns and/or microbial etiology.
Level III (low) Evidence comes from case studies and expert opinion.
CDC Guidelines
Evidence Level Definition
Category IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical or epidemiologic studies.
Category IB Strongly recommended for implementation and supported by some clinical or epidemiologic studies and by strong theoretical rationale.
Category IC Required for implementation, as mandated by federal or state regulation or standard.
Category II Required for implementation, as mandated by federal or state regulation or standard.
No Recommendation; Unresolved Practices for which insufficient issue evidence or no consensus exists about efficacy.
AACN Guidelines
Evidence Level Definition
Level VI Clinical studies in a variety of patient populations and situations to support recommendations.
Level V Clinical studies in a variety of patient populations and situations to support recommendations.
Level IV Limited clinical studies to support recommendations.
Level III Laboratory or bench data only; no clinical data to support recommendations.
Level II Theory based; no research data to support recommendations. Recommendations from expert consensus group may exist.
Level I Manufacturer recommendation only.
CCCS/CCCTG – AHRQ/IHI/SHN
x Denotes intervention recommended by guideline.
x(Consider) Denotes intervention marked as to be considered in guideline.
Intervention ATS/ISDA([FOOTNOTE=American Thoracic Society, 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(4):388-416.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805217]) CDC/ HICPAC([FOOTNOTE=Guidelines for preventing health-care-associated pneumonia, 2003 recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Respir Care. 2004;49(8):926-939.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=727209])
 CCCS/ CCCTG([FOOTNOTE=Dodek P, Keenan S, Cook D, et al; Canadian Critical Care Trials Group; Canadian Critical Care Society. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004;141(4):305-313.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805216]) AHRQ([FOOTNOTE=Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ). 2001;(43):i-x, 1-668.],[ANCHOR=],[LINK=])
 IHI([FOOTNOTE=Prevent Ventilator-Associated Pneumonia. Institute for Healthcare Improvement. 100,000 Lives Campaign. Available at:http://www.ihi.org/topics/VAP/Pages/default.aspx.],[ANCHOR=],[LINK=])
 AACN([FOOTNOTE=American Association of Critical Care Nurses. Practice Alert: Ventilator Associated Pneumonia. January 2008. http://www.aacn.org/clinical-resources/practice-alerts/ventilator-associated-pneumonia-vap.],[ANCHOR=],[LINK=]) SHN([FOOTNOTE=Safer Healthcare Now! Campaign April 2009 How-to Guide: Prevention of VAP. Available at:http://www.patientsafetyinstitute.ca/en/Topic/Pages/Ventilator-Associated-Pneumonia-(VAP).aspx?k=Ventilator-Associated%20Pneumonia%20(VAP) . Accessed October 21, 2013.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805209])
Continuous aspiration of subglottic secretions I II x(Consider) x   VI x
Enteral nutrition preferred to parenteral II UNRESOLVED ISSUE         xx
Maintain endotracheal cuff pressures >20 cm H2O II            
Oral preferred to nasal gastric tube placement II            
Oral preferred to nasal intubation II IB

 x       x
Recommendation for closed suction or single-use open suction   No Preference Closed Suction Recommended        
Intervention ATS/ISDA CDC/ HICPAC
 CCCS/ CCCTG AHRQ
 IHI
 AACN SHN
Appropriate hand disinfection

 I 1A         x
Contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or inline medication nebulizers II IB          
Develop and implement a comprehensive oral-hygiene program (which might include the use of an antiseptic agent) for patients in acute-care settings or residents in long-term care facilities at high risk of developing healthcare-associated pneumonia   II     x   x
Do not routinely change the patient’s ventilator circuit based on duration of use   IA x     VI  
Modulation of oropharyngeal colonization by the use of oral chlorhexidine Not Recommended UNRESOLVED ISSUE     x   x
Passive humidifiers or heat-moisture exchangers Unresolved UNRESOLVED ISSUE x        
Routine use of selective digestive decontamination Not Recommended UNRESOLVED ISSUE   x      
Semirecumbent positioning I II x x x VI x
Stress bleeding prophylaxis with either H2 antagonists or sucralfate Either UNRESOLVED ISSUE Sucralfate not recommended H2antagonists H2antagonists preferred/ consider PPIs    
Intervention ATS/ISDA CDC/HICPAC CCCS/ CCCTG AHRQ IHI AACN SHN
   
   
   
Avoid intubation and reintubation when possible I II          
Deep venous thrombosis (DVT) prophylaxis         x   x
Kinetic beds     x(Consider)        
Maintaining adequate staffing levels in the ICU II            
Noninvasive ventilation when possible I II          
Practices that promote patient mobility and autonomy

             x
Reduce duration of intubation and mechanical ventilation through protocols to improve the use of sedation and to accelerate weaning II       x   x
Staff education and involvement I 1A     x   x
Surveillance of ICU infections II 1B     x    
Tight glycemic control

 I            
ATS/IDSA Guidelines
Evidence Level Definition
Level I (high) Evidence comes from well-conducted, randomized controlled trials.
Level II (moderate) Evidence comes from well-designed, controlled trials without randomization or large case series with systematic analysis of disease patterns and/or microbial etiology.
Level III (low) Evidence comes from case studies and expert opinion.
CDC Guidelines
Evidence Level Definition
Category IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical or epidemiologic studies.
Category IB Strongly recommended for implementation and supported by some clinical or epidemiologic studies and by strong theoretical rationale.
Category IC Required for implementation, as mandated by federal or state regulation or standard.
Category II Required for implementation, as mandated by federal or state regulation or standard.
No Recommendation; Unresolved Practices for which insufficient issue evidence or no consensus exists about efficacy.
AACN Guidelines
Evidence Level Definition
Level VI Clinical studies in a variety of patient populations and situations to support recommendations.
Level V Clinical studies in a variety of patient populations and situations to support recommendations.
Level IV Limited clinical studies to support recommendations.
Level III Laboratory or bench data only; no clinical data to support recommendations.
Level II Theory based; no research data to support recommendations. Recommendations from expert consensus group may exist.
Level I Manufacturer recommendation only.
CCCS/CCCTG – AHRQ/IHI/SHN
x Denotes intervention recommended by guideline.
x(Consider) Denotes intervention marked as to be considered in guideline.
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