Ventilator-associated pneumonia (VAP) is a frequent and severe health-care associated infection. In Europe, pneumonia occur in 7.0% of patients staying at least 2 days in intensive care units (ICUs); 91% of these pneumonia are VAP . The proportion of VAP which is preventable is debated  but there is no doubt that a serious potential for harm reduction does exist [3, 4] and VAP prevention is becoming a major patient safety issue. In the US for instance, VAP prevention has been proposed as a national safety goal .
VAP prevention requires clinical interventions (best practice guidelines) combined with non clinical interventions to ensure implementation and compliance with these guidelines.
Clinical interventions for VAP prevention fall in three categories . The first, obvious one, is to limit exposure to mechanical ventilation by preferring non-mechanical ventilation when possible and limiting its duration when alternative options are not possible. Other prevention practices aim at reducing airways colonization (such as oral care decontamination using chlorhexidine ), or preventing aspiration  (e.g. by nursing in the semi-recumbent position, or maintaining a sufficient cuff pressure). Clinical interventions should be combined, in what is often called a “care bundle”. The precise content of VAP care bundle varies between guidelines [7, 8] because the number of items in a “bundle” should be limited, some prevention practices are controversial (e.g. selective digestive decontamination),  and recommending best practice regarding such measures requires compromise and pragmatism . There is no universally accepted “VAP care bundle”. A study aiming at defining a “European care bundle” ranked VAP prevention measures by combining criteria such as the strength of the supporting evidence, ease of implementation, and expected impact . The top 5 clinical interventions (we did not consider “trained staff” as a clinical intervention) were: 1) no ventilatory circuit change unless specifically indicated; 2) strict hand hygiene with alcohol especially before managing the airways; 3) daily sedation vacation and weaning protocol; 4) oral care with chlorhexidine; and 5) cuff pressure control at least every 24 hrs. It was beyond the scope of our study to assess the evidence behind each of these interventions, but none appears to be controversial.
Ensuring compliance with guidelines is a vast and complex field of research [11–13]. Common to any improvement strategy is the need for measurement; this serves evaluation purposes, measurement can also be the intervention, or a major component of it [14–16]. In a survey on infection control practices in the US, ICUs were only able to reduce heathcare-associated infection rates (including VAP), when they had a written policy, monitored compliance, and achieved a ≥95% compliance to all elements included in the local care bundle [11, 17]. Under the unchallenged assumption “if you cannot measure it, you cannot improve it” (Lord Kelvin, 1824-1907), we considered here that monitoring process (compliance to guidelines) and outcomes is a necessary, if not sufficient, component of any intervention aiming at decreasing VAP.
Accurate diagnosis of VAP is a challenge, because many conditions commonly encountered in critically ill patients – such as pulmonary oedema, pulmonary hemorrhage and acute respiratory distress syndrome, can mimic the signs and symptoms of pneumonia . Clinical diagnosis leads to treatment decisions, its primary aim is to be accurate, and it cannot be entirely standardized. By contrast measurement need primarily to be reproducible to ensure comparability of data overtime and allow evaluation of trends. Standardization is essential. Criteria for diagnosis and criteria for recording, therefore do not necessarily overlap entirely. Guidelines and definitions of VAP for recording and reporting exist in Europe  and in the United States . Despite some changes in the US, current case-definitions are still considered useful for internal quality improvement purposes .
Our objectives were to document, using a web-based survey (1) reported VAP prevention practices in ICUs (clinical practices, and measurement) and (2) attitudes towards the implementation of a measurement system. Our primary interest laid in providing estimates at European level, but we did not define exclusion criteria based on geographical location; on the other hand country-specific results can be used to steer prevention initiatives at country level.