Ventilator-Associated Pneumonia: An Update for Clinicians

Craven DE , Steger KA , Barber TW . Preventing nosocomial pneu-monia: state of the art and perspectives for the 1990s. Am J Med 1991;91(3, Part B):44S–53S.

Fagon JY , Chastre J , Domart Y , Trouillet JL , Pierre J , Darne C , Gibert C. Nosocomial pneumonia in patients receiving continuous me-chanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture technique. Am Rev Respir Dis 1989;139(4):877–884.

Torres A , Aznar R , Gatell JM , Jimenez P , Gonzalez J , Ferrer A , . Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 1990;142(3):523–528.

Craven DE , Kunches LM , Kilinsky V , Lichtenberg DA , Make BJ , McCabe WR . Risk factors for pneumonia and fatality in patients re-ceiving continuous mechanical ventilation. Am Rev Respir Dis 1986;133(5):792–796.

Craven DE , Kunches LM , Lichtenberg DA , Kollisch NR , Barry MA , Heeren TC , McCabe WR . Nosocomial infection and fatality in med-ical and surgical intensive care unit patients. Arch Intern Med 1988;148(5):1161–1168.

Celis R , Torres A , Gatell JM , Almela M , Rodriguez-Roisin R , Agusti-Vidal A. Nosocomial pneumonia. A multivariate analysis of risk and prognosis. Chest 1988;93(2):318–324.

Leu HS , Kaiser DL , Mori M , Woolson RF , Wenzel RP . Hospital-acquired pneumonia. Attributable mortality and morbidity. Am J Epi-demiol 1989;129(6):1258–1267.

Meduri GU , Johanson WG Jr . International consensus conference: clinical investigation of ventilator-associated pneumonia. Chest 1992;102(5, Suppl):551S–552S.

Fagon JY , Chastre J , Hance AJ , Montravers P , Novara A , Gibert C. Nosocomial pneumonia in ventilated patients: a cohort study eval-uating attributable mortality and hospital stay. Am J Med 1993;94(3):281–288.

Rello J , Ausina V , Ricart M , Castella J , Prats G. Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-as-sociated pneumonia. Chest 1993;104(16):1230–1235.

Kollef MH . Ventilator-associated pneumonia: a multivariate anal-ysis. JAMA 1993;270(16):1965–1970.

Jimenez P , Torres A , Rodriguez-Roisin R , de la Bellacasa JP , Aznar R , Gatell JM , Agusti-Vidal A. Incidence and etiology of pneumonia acquired during mechanical ventilation. Crit Care Med 1989;17(9):882–885.

Driks MR , Craven DE , Celli BR , Manning M , Burke RA , Garvin GM , . Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. The role of gastric colinization. N Engl J Med 1987;317(22):1376–1382.

Tryba M. Risk of acute stress bleeding and nosocomial pneumonia in ventilated intensive care unit patients: sucralfate versus antacids. Am J Med 1987;83(3, Suppl):117–124.

Torres A , Serra-Batlles J , Ros E , Piera C , de la Bellacasa JP , Cobos A , . Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 1992;116(7):540–543.

Montecalvo MA , Steger KA , Farber HW , Smith BF , Dennis RC , Fitzpatrick GF , . Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. Crit Care Med 1992;20(10):1377–1387.

Marian M , Rappaport W , Cunningham D , Thompson C , Esser M , Williams F , Warneke J , Hunter G. The failure of conventional meth-ods to promote spontaneous transpyloric feeding tube passage and the safety of intragastric feeding in the critically ill ventilated patient. Surg Gynecol Obstet 1993;176(5):475–479.

Craven DE , Connolly MG Jr , Lichtenberg DA , Primeau PJ , McCabe WR . Contamination of mechanical ventilators with tubing changes every 24 or 48 hours. N Engl J Med 1982;306(25):1505–1509.

Meyer KS , Urban C , Eagan JA , Berger BJ , Rahal JJ . Nosocomial outbreak of klebsiella infection resistant to late-generation cepha-losporins. Ann Intern Med 1993;119(5):353–358.

Chow JW , Fine MJ , Shlaes DM , Quinn JP , Hooper DC , Johnson MP , . Enterobacter bacteremia: clinical features and emergence of antibiotic resistance during therapy. Ann Intern Med 1991;115(8):585–590.

Struelens MJ , Carlier E , Maes N , Serruys E , Quint WG , van Belkum A. Nosocomial colonization and infection with multiresistant Acine-tobacter baumannii: outbreak delineation using DNA macrorestriction analysis and PCR-fingerprinting. J Hosp Infect 1993;25(1):15–32.

Rello J , Ausina V , Ricart M , Puzo C , Quintana E , Net A , Prats G. Risk factors for infection by Pseudomonas aeruginosa in patients with ventilator-associated pneumonia. Intensive Care Med 1994;20(3):193–198.

Kollef MH , Wragge T , Pasque C. Determinants of multiorgan dys-function in cardiac surgery patients requiring prolonged mechani-cal ventilation. Chest 1995;107(5):1395–1401.

Rello J , Torres A , Ricart M , Valles J , Gonzalez J , Artigas A , Rodriguez-Roisin R. Ventilator-associated pneumonia by Staphylococcus au-reus. Comparison of methicillin-resistant and methicillin-sensitive episodes. Am J Respir Crit Care Med 1994;150:1545–1549.

Rello J , Ricart M , Ausina V , Net A , Prats G. Pneumonia due to Haemophilus influenzae among mechanically ventilated patients. In-cidence, outcome, and risk factors. Chest 1992;102(5):1562–1565.

Klick JM , duMoulin CC , Hedley-Whyte J , Teres C , Bushnell LS , Feingold DS . Prevention of gram-negative bacillary pneumonia using polymyxin aerosol as prophylaxis. II. Effect on the incidence of pneu-monia in seriously ill patients. J Clin Invest 1975;55(3):514–519.

Gastinne H , Wolff M , Delatour F , Faurisson F , Chevret S. The French Study Group on Selective Decontamination of the Digestive Tract. A controlled trial in intensive care units of selective decontamina-tion of the digestive tract with nonabsorbable antibiotics. N Engl J Med 1992;326(9):594–599.

Daschner F. Emergence of resistance during selective decontami-nation of the digestive tract. Eur J Clin Microbiol Infect Dis 1992;11(1):1–3.

Bonten MJ , van Tiel FH , van der Geest S , Stobberingh EE , Gail-lard CA . Enterococcus faecalis pneumonia complicating topical an-timicrobial prophylaxis. N Engl J Med 1993;328(3):209–210.

Nau R , Ruchel R , Mergerian H , Wegener U , Winkelmann T , Prange HW . Emergence of antibiotic-resistant bacteria during selective decontamination of the digestive tract. J Antimicrob Chemother 1990;25(5):881–883.

Kollef MH , Silver P , Murphy DM , Trovillion E. The effect of late-onset ventilator-associated pneumonia in determining patient mor-tality. Chest (1995, in Press).

Boyce JM , Potter-Bynoe G , Dziobek L , Solomon SL . Nosocomial pneumonia in Medicare patients. Hospital costs and reimbursement patterns under the prospective payment system. Arch Intern Med 1991;151(6):1109–1114.

Kelleghan SI , Salemi C , Padilla S , McCord M , Mermilliod G , Canola T , Becker L. An effective continuous quality improvement approach to the prevention of ventilator-associated pneumonia. Am J Infect Control 1993;21(6):322–330.

Fiddian-Green RG , Baker S. Nosocomial pneumonia in the critically ill: product of aspiration or translocation? Crit Care Med 1991;19(6):763–769.

Huxley EJ , Viroslav J , Gray WR , Pierce AK . Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med 1978;64(4):564–568.

Johanson WG Jr , Seidenfeld JJ , de los Santos R , Coalson JJ , Gomez P. Prevention of nosocomial pneumonia using topical and parenteral antimicrobial agents. Am Rev Respir Dis 1988;137(2):265–272.

Berendt RF . Relationship of method of administration to respiratory virulence of Klebsiella pneumoniae for mice and squirrel monkeys. Infect Immun 1978;20(2):581–583.

Greene R , Thompson S , Jantsch HS , Teplick R , Cullen DJ , Greene EM , Whitman GJ , Hulka CA , Llewellyn HJ . Detection of pooled secre-tions above endotracheal-tube cuffs: value of plain radiographs in sheep cadavers and patients. AJR 1994;163:1333–1337.

Rouby JJ , Laurent P , Gosnach M , Cambau E , Lamas G , Zouaoui A , . Risk factors and clinical relevance of nosocomial maxillary si-nusitis in the critically ill. Am J Respir Crit Care Med 1994;150(3):776–783.

Heffner JE . Nosocomial sinusitis. Den of multiresistant thieves? Am J Respir Crit Care Med 1994;150(3):608–609.

Scannapieco FA , Stewart EM , Mylotte JM . Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med 1992;20(6):740–745.

Heyland D , Mandell LA . Gastric colonization by gram-negative bacil-li and nosocomial pneumonia in the intensive care unit patient. Ev-idence for causation. Chest 1992;101(1):187–193.

Giannella RA , Broitman SA , Zamcheck N. Influence of gastric acid-ity on bacterial and parasitic enteric infections. A perspective. Ann Intern Med 1973;78(2):271–276.

Donowitz LG , Page MC , Mileur GL , Guenthner SH . Alteration of normal gastric flora in critical care patients receiving antacid and cime-tidine therapy. Infect Control 1986;7(1):23–26.

DuMoulin GC , Paterson DG , Hedley-Whyte J , Lisbon A. Aspiration of gastric bacteria in antacid-treated patients: a frequent cause of post-operative colonization of the airway. Lancet 1982;1(8266):242–245.

George DL . Epidemiology of nosocomial pneumonia in intensive care unit patients. Clin Chest Med 1995;16(1):29–44.

Craven DE , Steger KA . Epidemiology of nosocomial pneumonia. New perspectives on an old disease. Chest 1995;108:15–16S.

Noseworthy TW , Cook DJ . Nosocomial pneumonia, prophylaxis against gastric erosive disease, and clinically important gastrointestinal bleeding: where do we stand? Crit Care Med 1993;21(12):1814–1816.

Pickworth KK , Falcone RE , Hoogeboom JE , Santanello SA . Oc-currence of nosocomial pneumonia in mechanically ventilated trau-ma patients: a comparison of sucralfate and ranitidine. Crit Care Med 1993;21(12):1856–1862.

Metz CA , Livingston DH , Smith JS , Larson GM , Wilson TH . Im-pact of multiple risk factors and ranitidine prophylaxis on the de-velopment of stress-related upper gastrointestinal bleeding: a prospec-tive, multicenter, double-blind, randomized trial. Crit Care Med 1993;21(12):1844–1849.

Prod'hom G , Leuenberger P , Koerfer J , Blum A , Chiolero R , Schaller MD , . Nosocomial pneumonia in mechanically venti-lated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer: a randomized controlled trial. Ann Intern Med 1994;120(8):653–662.

Ben-Menachem T , Fogel R , Patel RV , Touchette M , Zarowitz BJ , Hadzijahic N , . Prophylaxis for stress-related gastric hemorrhage in the medical intensive care unit. A randomized, controlled, single-blind study. Ann Intern Med 1994;121(8):568–575.

Canadian Critical Care Trials Group. Cook DJ , Fuller HD , Guyatt GH , Marshall JC , Leasa D , Hall R , . Risk factors for gas-trointestinal bleeding in critically ill patients. N Engl J Med 1994;330(6):377–381.

Meduri GU . Ventilator-associated pneumonia in patients with res-piratory failure. A diagnostic approach. Chest 1990;97(5):1208–1219.

Meduri GU . Diagnosis and differential diagnosis of ventilator-as-sociated pneumonia. Clin Chest Med 1995;16(1):61–93.

Andrews CP , Coalson JJ , Smith JD , Johanson WG Jr . Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury. Chest 1981;80(3):254–258.

Fagon JY , Chastre J , Hance AJ , Guiguet M , Trouillet JL , Domart Y , Pierre J , Gibert C. Detection of nosocomial lung infection in ven-tilated patients. Use of a protected specimen brush and quantitative culture techniques in 147 patients. Am Rev Respir Dis 1988;138(1):110–116.

Fagon JY , Chastre J , Hance AJ , Domart Y , Trouillet JL , Gibert C. Evaluation of clinical judgement in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest 1993;103(2):547–553.

Rubin SA , Winer-Muram HT , Ellis JV . Diagnostic imaging of pneu-monia and its complications in the critically ill patient. Clin Chest Med 1995;16(1):45–59.

Wunderink RG , Woldenberg LS , Zeiss J , Day CM , Ciemins J , Lacher DA . The radiologic diagnosis of autopsy-proven ventilator-associated pneumonia. Chest 1992;101(2):458–463.

Leeper KV Jr . Diagnosis and treatment of pulmonary infections in adult respiratory distress syndrome. New Horizons 1993;1(4):550–562.

Fagon JY , Chastre J , Trouillet JL , Domart Y , Dombret MC , Bornet M , Gibert C. Characterization of distal bronchial microflora during acute exacerbation of chronic bronchitis. Use of the protected specimen brush technique in 54 mechanically ventilated patients. Am Rev Respir Dis 1990;142(5):1004–1008.

Salata RA , Lederman MM , Shlaes DM , Jacobs MR , Eckstein E , Tweardy D , . Diagnosis of nosocomial pneumonia in intubat-ed, intensive care unit patients. Am Rev Respir Dis 1987;135(2):426–432.

Shlaes DM , Lederman MM , Chmielewski R , Tweardy D , Krause G , Saffai C. Sputum elastin fibers and the diagnosis of necrotizing pneu-monia. Chest 1984;85(6):763–766.

Marquette CH , Georges H , Wallet F , Ramon P , Saulnier F , Nevierre R , . Diagnostic efficiency of endotracheal aspirates with quantitative bacterial cultures in intubated patients with suspected pneumonia. Comparison with the protected specimen brush. Am Rev Respir Dis 1993;148(1):138–144.

el-Ebiary M , Torres A , Gonzalez J , de la Bellacasa JP , Garcia C , Jimenez de Anta MT , . Quantitative cultures of endotracheal as-pirates for the diagnosis of ventilator-associated pneumonia. Am Rev Respir Dis 1993;148(6, Part 1):1552–1557.

Marquette CH , Copin MC , Wallet F , Neviere R , Saulnier F , Mathieu D , . Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard. Am J Respir Crit Care Med 1995;151(6):1878–1888.

Wunderink RG , Russell GB , Mezger E , Adams D , Popovich J Jr . The diagnostic utility of antibody coated bacteria test in intubated patients. Chest 1991;99(1):84–88.

Wimberley N , Faling LJ , Bartlett JG . A fiberoptic bronchoscopy tech-nique to obtain uncontaminated lower airway secretions for bacte-rial culture. Am Rev Respir Dis 1979;119(3):337–343.

Chastre J , Viau F , Brun P , Pierre J , Dauge MC , Bouchama A , . Prospective evaluation of the protected specimen brush for the di-agnosis of pulmonary infections in ventilated patients. Am Rev Respir Dis 1984;130(5):924–929.

Higuchi JH , Coalson JJ , Johanson WG Jr . Bacterial diagnosis of noso-comial pneumonia in primates. Usefulness of the protected speci-men brush. Am Rev Respir Dis 1982;125(1):53–57.

Meduri GU , Chastre J. The standardization of bronchoscopic tech-niques for ventilator-associated pneumonia. Chest 1992;102(5, Suppl):557S–564S.

Baselski VS , El-Torky M , Coalson JJ , Griffin JP . The standardiza-tion of criteria for processing and interpreting laboratory specimens in patients with suspected ventilator-associated pneumonia. Chest 1992;102(5, Suppl):571S–579S.

Chastre J , Fagon JY , Bornet-Lecso M , Calvat S , Dombret M-C , Al Khani R , . Evaluation of bronchoscopic techniques for the di-agnosis of nosocomial pneumonia. Am J Respir Crit Care Med 1995;152:231–240.

Baker AM , Bowton DL , Haponik EF . Decision making in nosoco-mial pneumonia. An analytic approach to the interpretation of quan-titative bronchoscopic cultures. Chest 1995;107(1):85–95.

Niederman MS , Torres A , Summer W. Invasive diagnostic testing is not needed routinely to manage suspected ventilator-associated pneumonia. Am J Respir Crit Care Med 1994;150(2):565–569.

Torres A , el-Ebiary M , Padro L , Gonzalez J , de la Bellacasa JP , Ramirez J , . Validation of different techniques for the diagno-sis of ventilator-associated pneumonia. Comparison with immedi-ate post mortem pulmonary biopsy. Am J Respir Crit Care Med 1994;149(2, Part 1):324–331.

Dotson RG , Pingleton SK . The effect of antibiotic therapy on recovery of intracellular bacteria from bronchoalveolar lavage in suspected ventilator-associated nosocomial pneumonia. Chest 1993;103(2):541–546.

Pham LH , Brun-Busson C , Legrand P , Rauss A , Verra F , Brochard L , Lemaire F. Diagnosis of nosocomial pneumonia in mechanically ven-tilated patients. Comparison of a plugged telescoping catheter with the protected specimen brush. Am Rev Respir Dis 1991;143(5, Part 1):1055–1061.

Papazian L , Martin C , Meric B , Dumon JF , Gouin F. A reappraisal of blind bronchial sampling in the microbiologic diagnosis of noso-comial bronchopneumonia: a comparative study in ventilated patients. Chest 1993;103(1):236–242.

Leal-Noval SR , Alfaro-Rodriguez E , Murillo-Cabeza F , Garnacho-Montero J , Rey-Perez J , Munoz-Sanchez MA . Diagnostic value of the blind brush in mechanically ventilated patients with nosocomi-al pneumonia. Intensive Care Med 1992;18(7):410–414.

Rouby JJ , De Lassale EM , Poete P , Nicolas MH , Bodin L , Jarlier V , . Nosocomial bronchopneumonia in the critically ill. Histologic and bacteriologic aspects. Am Rev Respir Dis 1992;146(4):1059–1066.

Kollef MH , Bock KR , Richards RD , Hearns ML . The safety and di-agnostic accuracy of minibronchoalveolar lavage in patients with sus-pected ventilator-associated pneumonia. Ann Intern Med 1995;122(10):743–748.

A'Court CH , Garrard CS , Crook D , Bowler I , Conlon C , Peto T , An-derson E. Microbiologic lung surveillance in mechanically venti-lated patients, using non-directed bronchial lavage and quantitative culture. Q J Med 1993;86(10):635–648.

Chastre J , Fagon JY . Invasive diagnostic testing should be routinely used to manage ventilated patients with suspected pneumonia. Am J Respir Crit Care Med 1994;150(2):570–574.

Cook DJ , Brun-Buisson C , Guyatt GH , Sibbald WJ . Evaluation of new diagnostic technologies: bronchoalveolar lavage and the di-agnosis of ventilator-associated pneumonia. Crit Care Med 1994;22(8):1314–1322.

Bonten MJ , Gaillard CA , Wouters EF , van Tiel FH , Stobberingh EE , van der Geest S. Problems in diagnosing nosocomial pneumonia in mechanically ventilated patients: a review. Crit Care Med 1994;22(10):1683–1691.

Pugin J , Auckenthaler R , Mili N , Janssens JP , Lew PD , Suter PM . Diagnosis of ventilator-associated pneumonia by bacteriologic anal-ysis of bronchoscopic and nonbronchoscopic "blind" bronchoalveolar lavage fluid. Am Rev Respir Dis 1991;143(5, Part 1):1121–1129.

Feeley TW , DuMoulin GC , Hedley-Whyte J , Bushnell LS , Gilbert JP , Feingold DS . Aerosol polymyxin and pneumonia in seriously ill pa-tients. N Engl J Med 1975;293(10):471–475.

Greenfield S , Teres D , Bushnell LS , Hedley-Whyte J , Feingold DS . Prevention of gram-negative bacillary pneumonia using aerosol polymyxin as prophylaxis. I. Effect on the colonization pattern of the upper respiratory tract of seriously ill patients. J Clin Invest 1973;52(11):2935–2940.

Kollef MH . The role of selective digestive tract decontamination on mortality and respiratory tract infections. A meta-analysis. Chest 1994;105(4):1101–1108.

Selective Decontamination of the Digestive Tract Trialist's Col-laborative Group. Meta-analysis of randomised controlled trials of selective decontamination of the digestive tract. BMJ 1993;307(6903):525–532.

Heyland DK , Cook DJ , Jaeschke R , Griffith L , Lee HN , Guyatt GH . Selective decontamination of the digestive tract. An overview. Chest 1994;105(4):1221–1229.

The American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee. Bone RC , Balk RA , Cerra FB , Dellinger RP , Fein AM , Knaus WA , . Definition for sepsis and organ failure and guidelines for the use of innovative ther-apies in sepsis. Chest 1992;101(6):1644–1655.

Rangel-Frausto MS , Pittet D , Costigan M , Hwang T , Davis CS , Wen-zel RP . The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. JAMA 1995;273(2):117–123.

Doebbeling BN , Stanley GL , Sheetz CT , Pfaller MA , Houston AK , Annis L , Li N , Wenzel RP . Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med 1992;327(2):88–93.

Maki DG . Control of colonization and transmission of pathogenic bacteria in the hospital. Ann Intern Med 1978;89(5, Part 2):777–780.

Klein BS , Perloff WH , Maki DG . Reduction of nosocomial infec-tion during pediatric intensive care by protective isolation. N Engl J Med 1989;320(26):1714–1721.

Bassin AS , Niederman MS . Prevention of ventilator-associated pneu-monia. An attainable goal?. Clin Chest Med 1995;16(1):195–208.

Tryba M. Sucralfate versus antacids of H2-antagonists for stress ulcer prophylaxis: a meta-analysis on efficacy and pneumonia rate. Crit Care Med 1991;19:942–949.

Cook DJ , Laine LA , Guyatt GH , Raffin TA . Nosocomial pneumonia and the role of gastric pH. A meta-analysis. Chest 1991;100(1):7–13.

Cook DJ , Reeve BK , Scholes LC . Histamine-2-receptor antagonists and antacids in the critically ill population: stress ulceration versus nosocomial pneumonia. Infect Control Hosp Epidemiol 1994;15:437–442.

Mahul P , Auboyer C , Jospe R , Ros A , Guerin C , el Khouri Z , . Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer pro-phylaxis. Intensive Care Med 1992;18(1):20–25.

Valles J , Artigas A , Rello J , Bonsoms N , Fontanals D , Blanch L , . Continuous aspiration of subglottic secretions in preventing ven-tilator-associated pneumonia. Ann Intern Med 1995;122(3):179–186.

Kollef MH . antibiotic use and antibiotic resistance in the intensive care unit: Are we curing or creating disease? Heart Lung 1994;23:363–367.

Craven DE , Goularte TA , Make BJ . Contaminated condensate in me-chanical ventilator circuits. A risk factor for nosocomial pneumo-nía?. Am Rev Respir Dis 1984;129(4):625–628.

Kollef MH , Shapiro SD , Fraser VJ , Silver P , Murphy DM , Trovillion E , . Mechanical ventilation with or without 7-day circuit changes: a randomized controlled trial. Ann Intern Med 1995;123(2):168–174.

Dreyfuss D , Djedaini K , Weber P , Brun P , Lanore JJ , Rahamani J , . Prospective study of nosocomial pneumonia and of patient and circuit colonization during mechanical ventilation with circuit changes every 48 hours versus no change. Am Rev Respir Dis 1991;143(4, Part 1):738–743.

Hess D , Burns E , Romagnoli D , Kacmarek RM . Weekly ventilator circuit changes. A strategy to reduce costs without affecting pneu-monia rates. Anesthesiology 1995;82(4):903–911.

Dreyfuss D , Djedaini K , Gros I , Mier L , Le-Bourdelles G , Cohen Y , . Mechanical ventilation with heated humidifiers or heat and moisture exchangers: effects on patient colonization and incidence of nosocomial pneumonia. Am J Respir Crit Care Med 1995;151(4):986–992.

Tablan OC , Anderson LJ , Arden NH , Breiman RF , Butler JC , McNeil MM , Hospital Infection Control Practices Advisory Commit-tee. Guideline for prevention of nosocomial pneumonia. Respir Care 1994;39(12):1191–1236.

The Intravenous Immunoglobulin Collaborative Study Group. Pro-phylactic intravenous administration of standard immune globulin as compared with core-lipopolysaccharide immune globulin in pa-tients at high risk of postsurgical infection. N Engl J Med 1992;327(4):234–240.

Sahn SA . Continuous lateral rotational therapy and nosocomial pneu-monia. Chest 1991;99(5):1263–1267.

Fink MP , Helsmoortel CM , Stein KL , Lee PC , Cohn SM . The ef-ficacy of an oscillating bed in the prevention of lower respiratory tract infection in critically ill victims of blunt trauma. A prospective study. Chest 1990;97(1):132–137.

deBoisblanc BP , Castro M , Everret B , Grender J , Walker CD , Sum-mer WR . Effect of air-supported, continuous, postural oscillation on the risk of early ICU pneumonia in nontraumatic critical illness. Chest 1993;103(5):1543–1547.

Bergogne-Berezin E. Treatment and prevention of nosocomial pneu-monia. Chest 1995;108:26S–34S.

Gisselbrecht C , Prentice HG , Bacigalupo A , Biron P , Milpied N , Rubie H , . Placebo-controlled phase III trial of lenograstim in bone-marrow transplantation. Lancet 1994;343(8899):696–700.

Maher DW , Lieschke GJ , Green M , Bishop J , Stuart-Harris R , Wolf M , . Filgrastim in patients with chemotherapy-induced febrile neu-tropenia. A double-blind, placebo-controlled trial. Ann Intern Med 1994;121(7):492–501.

Pizzo PA . Current issues in the antibiotic primary management of the febrile neutropenic cancer patient: a perspective from the National Cancer Institute. J Hosp Infect 1990;15(Suppl A):41–48.

Dever LL , Johanson WG Jr . Nosocomial pneumonia. In: Sim-mons DH, Tierney DF, editors. Current pulmonology, vol. 13. St. Louis: Mosby, 1993:1–28.

Moore RD , Smith CR , Lietman PS . Association of aminoglycoside plasma levels with therapeutic outcome in gram-negative pneumonia. Am J Med 1984;77(4):657–662.

Kim JH , Gallis HA . Observations on spiraling empiricism: its caus-es, allure, and perils, with particular reference to antibiotic therapy. Am J Med 1989;87(2):201–206.