Journal of Antimicrobial Chemotherapy (2007) 60, 206– 213

doi:10.1093/jac/dkm176
Advance Access publication 31 May 2007

Hospital-acquired pneumonia guidelines in Europe: a review of their

status and future development

R. Masterton1*, D. Craven2,3, J. Rello4, M. Struelens5, N. Frimodt-Moller6, J. Chastre7, A. Ortqvist8,

G. Cornaglia9, H. Lode10, H. Giamarellou11, M. J. M. Bonten12, H. Eraksoy13 and P. Davey14
1
NHS Ayrshire and Arran, Eglington House, Ailsa Hospital, Dalmellington Road, Ayr KA6 0BA, UK; 2Lahey
Clinic Medical Center, Burlington, MA, USA; 3Tufts University School of Medicine, Boston, MA, USA; 4Joan
XXIII University Hospital, University Rovira and Virgili, CIBERes 06-06-0036, Tarragona, Spain; 5Hôpital
Erasme, Belgium; 6National Centre for Antimicrobial Infection Control, Copenhagen, Denmark; 7GH Pitié-
Salpêtrière, AP-HP, Paris, France; 8Karolinska Institutet Stockholm, Stockholm, Sweden; 9University of Verona,
Verona, Italy; 10City Hospital, Berlin, Germany; 11Attikon University Hospital, Athens, Greece;
12
University Medical Center, Utrecht, The Netherlands; 13Istanbul University, Istanbul, Turkey;
14
University of Dundee, Dundee, Scotland, UK

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Hospital-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 formu-
lation, coverage of different disease aspects and overall recommendations. Development of compre-
hensive 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 prin-
ciples 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 develop-
ment 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 contro-
versies and identifying previously unconsidered aspects of HAP. Establishing a pan-European consen-
sus on core processes of care should be viewed as an impetus for change to improve clinical
practices and should include a suitable implementation strategy.

Keywords: European consensus, guideline development, implementation

Introduction estimated to increase hospital stay by 7– 9 days.7,8 In a pro-

portion of patients, HAP is associated with mechanical venti-
Hospital-acquired pneumonia (HAP) is a respiratory infection lation, in which case it is termed as ventilator-associated
developing more than 48 h after hospital admission and affects pneumonia (VAP).9 In patients with VAP there is a 20% to 55%
0.5% to 1.7% of patients.1 – 4 HAP is the most common mortality rate and a mean increase in the duration of hospital
healthcare-acquired infection contributing to death5,6 and is stay of 6 days.10 Mortality increases to 76% if infection is

.....................................................................................................................................................................................................................................................................................................................................................................................................................................

*Corresponding author. Tel: þ44-1292-614510; Fax: þ44-1292-288952; E-mail: robert.masterton@aaaht.scot.nhs.uk

.....................................................................................................................................................................................................................................................................................................................................................................................................................................

206
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 Review
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 diffi-
cult 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 dra-
matically 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 develop-
ing an overarching pan-European consensus document, to com-
prehensively 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.
Existing European HAP guidelines
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 sum-
marized 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.
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 associ-
ated with a substantial time burden and, as a result, evidence
grading was only implemented for five country-specific guide-
lines. The draft UK15 guidelines adopted the formalized Scottish
Intercollegiate Guidelines Network (SIGN) assessment method-
ology, 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
207
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 rec-
ommendations 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, preven-
tion 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 treat-
ment (one guideline) and treatment dosages (one guideline).
HAP diagnosis (eight guidelines)
A universal problem associated with development of the diag-
nostic HAP guidelines was interpreting weak data. Almost all
research in this area relates to VAP and the validity of its extra-
polation to HAP is uncertain. Some systematic reviews and ran-
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domized 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 quantitat-
ive 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 appro-
priate therapy for HAP. HAP treatment guidelines were reason-
ably 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 intrave-
nous 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 differ-
ence between countries was associated with the different
microbial antibiotic resistance profiles occurring across Europe.
Differences in antibiotic resistance profiles, even within individ-
ual countries, were noted as being problematical when develop-
ing treatment guidelines. As a result, most country-specific HAP
 Review

Table 1. Summary of European country-specific HAP guidelines

Country Year Scope Method Diagnosis Treatment Prevention

Germany16 2003 HAP/VAP CO/SR   

France20 2004 HAP/VAP/HCAP CO   
Spain18 2004 HAP/VAP CO  
UK15 2006 HAP/VAP/HCAP SR   
The Netherlands17 2006 VAP CO 
Greece21 2006 HAP/VAP/HCAP CO/SR   
Turkey22 2002 HAP/VAP CO   
Denmark23 2006 HAP/VAP/HCAP CO   
Belgium24 2002 HAP/VAP CO  
Sweden19 2006 HAP/VAP CO 

SR, systematic review; CO, consensus opinion.

Table 2. Composition of country-specific HAP guideline working parties

Country Intensivist Microbiologist ID physician Respiratory physician Anaesthetist Radiologist ICN

    

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Germany
France  
Spain    
UK     
The Netherlands  
Greece   
Turkey      
Denmark    
Belgium      
Sweden   

ICN, infection control nurse.

guidelines indicated that the empirical treatment of choice
should be determined based on current, local antibiotic suscepti-
bility 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 guide-
lines covered a wide range of themes that could be grouped into
areas of educational aspects, ventilation, patient process inter-
ventions 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 recommen-
dations given by the different country-specific guidelines. The
only areas where recommendations were routinely in agreement
comprised the applicability of hand hygiene measures, the pre-
ferential use of non-invasive ventilation and the appropriateness
of patient positioning strategies. A degree of controversy was
associated with recommendations considering stress ulcer pro-
phylaxis, the use of heat moisture exchanger circuits and SDD.
Model guidelines
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 prolifer-
ation 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 meth-
odology 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 litera-
ture reviews already captured in the existing documents. Indeed
trans-contextual adaptation of guidelines is increasingly being

208
 Review
considered as an alternative to de novo guideline development,
and recent guidance suggests an appropriate approach.26
The development of comprehensive HAP guidelines is com-
plicated by issues that are associated with the quality of the sup-
porting 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 analy-
sis 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 find-
ings. 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 con-
sistency into the evidence assessment process, which is particu-
larly 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 limit-
ation curtailing the development of rigorous evidence-based
guidelines.
Approaches to guideline development
The Scottish Intercollegiate Guidelines Network approach
SIGN has been developing standardized methodologies for clini-
cal 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 litera-
ture 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 consider-
ation 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 guide-
lines, 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 advan-
tageous when updating guidelines. The use of data-sharing strat-
egies 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.
209
† 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 dis-
cussion of the data supporting each topic, with the level of evi-
dence supporting each recommendation being explicitly stated.
Principles for HAP guidelines
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 result-
ing recommendations is graded accordingly. When considering
the production of pan-European HAP guidelines, the involve-
ment of experts from diverse geographical locations was con-
sidered 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
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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.
HAP diagnosis
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 organ-
isms) 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 microbiologi-
cal sampling techniques.
† The timing of microbiological sampling.
† The effectiveness of quantitative, semi-quantitative and quali-
tative 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.
HAP treatment
Given the differences in antibiotic resistance profiles across
different countries, consideration of HAP treatment should
 Review
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 poss-
ible 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 health-
care facilities, time of HAP onset and local bacteriological epide-
miology. There were considered to be two treatment approaches
requiring assessment:
† Empirical treatment according to HAP severity and local anti-
biotic 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 under-
going additional treatment for Pseudomonas and MRSA.
Other important issues were the principles of treating patients
with and without sepsis. Maintaining optimal blood sugar, hae-
matocrit, ventilation and fluid control were also considered
relevant. Following initiation of treatment, the optimal manage-
ment 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
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 subglot-
tic 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.
Pan-European HAP guidelines
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
210
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 guide-
line 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, compris-
ing interventions that independently affect patient mortality and
morbidity.14
Coordinated work on pan-European guidelines represents an
ideal time to set priorities for new research by identifying con-
troversies 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.
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Considering aspects of HAP prevention, the impact of monitor-
ing environmental contamination and the use of closed suction-
ing 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 phar-
macoeconomic or health economic studies addressing the
benefits of HAP diagnostic, treatment or prevention measures.
This situation is not unique to HAP guidelines, with little evi-
dence 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 import-
ant 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.
Guideline implementation
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, evi-
dence 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 sup-
ported by high levels of consensus and consistency of view
 Review

Table 3. Principles for the production of pan-European HAP guidelines

Principle

Evidence grading † development of a central evidence database

† use of data-sharing strategies
† clear description of methodological approach
† audit trail of the evidence grading process and material assessed
Evidence assessment † implement systematic review approach
† use formal research quality assessment mechanism (e.g. SIGN)
† include explicit description of level and volume of evidence base
Guideline development † multi-disciplinary guideline development teams
† inclusion of lay persons on guideline development teams
† clear grading of final recommendations according to quality
of supporting evidence
† expert opinion should be included only in the absence of quality
data and should be high-lighted as such
Guideline quality † robust/transparent peer review process
† monitor guideline quality e.g. using the Appraisal of Guidelines
for Research and Evaluation (AGREE)33 instrument
† disclosure of conflicts of interest by guideline developers
Guideline implementation † national/institutional endorsement
† support of scientific societies
† establish local ownership of guidelines across all sectors of hospital staff

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† effective communication at the national and local level (guideline ‘champions’)
† practical implementation methods focusing on a few key recommendations
† identify resource implications
† development of educational materials and treatment algorithms to facilitate
local adaptation of guidelines
Guideline audit † point prevalence studies
† national benchmarking systems
† audit templates developed for key performance indicators
† impact assessment
Guideline update † regular updates as evidence base changes/develops
† update facilitated by central evidence database
† update facilitated by clear audit trail from the original evidence assessment

amongst professionals who work in partnership with patient
representatives and organizations.
Key aspects of improving evidence quality, through the pro-
duction of pan-European HAP guidelines, were discussed by the
meeting participants and are summarized in Table 3. When con-
sidered in terms of the model for implementation, key elements
for creating high-impact evidence include:
† Gaining acceptance of guideline recommendations from prac-
titioners in all clinical disciplines concerned with treating
HAP. Participation of all such treatment disciplines in guide-
line 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 edu-
cation packages are key to engendering an ethos of responsi-
bility 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 defin-
ing 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 guide-
line committee.27 A panel of suitable impact assessment tools is
currently being considered by the UK HAP guideline develop-
ment committee.

211
 Review
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 improve-
ment. Undertaking this work in a pan-European context will
significantly enhance the opportunities for supporting training,
through the involvement of professional societies by incorporat-
ing 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 pro-
cesses are grouped into simple bundles, caregivers are more
likely to implement them and make fundamental changes in pro-
cedures. 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 respirat-
ory therapists.14
Conclusions
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 con-
sidered. Development of a pan-European consensus HAP guide-
line 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 strat-
egy. One approach could be to target a small number of achiev-
able key objectives for implementation that could be packaged
into a care bundle.
Acknowledgements
The European HAP guideline consensus meeting was supported
by Wyeth International.
Transparency declarations
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
212
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 honor-
aria 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,
Downloaded from jac.oxfordjournals.org by guest on May 24, 2011
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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