Subscribe to this journal
Advanced Search
 array:23 [
  "pii" => "S217357271400023X"
  "issn" => "21735727"
  "doi" => "10.1016/j.medine.2013.12.001"
  "estado" => "S300"
  "fechaPublicacion" => "2014-05-01"
  "aid" => "662"
  "copyright" => "Elsevier España, S.L. and SEMICYUC"
  "copyrightAnyo" => "2013"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "fla"
  "cita" => "Med Intensiva. 2014;38:226-36"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 14971
    "formatos" => array:3 [
      "EPUB" => 235
      "HTML" => 11231
      "PDF" => 3505
    ]
  ]
  "Traduccion" => array:1 [
    "en" => array:19 [
      "pii" => "S0210569114000126"
      "issn" => "02105691"
      "doi" => "10.1016/j.medin.2013.12.007"
      "estado" => "S300"
      "fechaPublicacion" => "2014-05-01"
      "aid" => "662"
      "copyright" => "Elsevier España, S.L. and SEMICYUC"
      "documento" => "article"
      "crossmark" => 0
      "subdocumento" => "fla"
      "cita" => "Med Intensiva. 2014;38:226-36"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 9993
        "formatos" => array:3 [
          "EPUB" => 183
          "HTML" => 6789
          "PDF" => 3021
        ]
      ]
      "en" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>"
        "titulo" => "Guidelines for the prevention of ventilator-associated pneumonia and their implementation&#46; The Spanish &#8220;Zero-VAP&#8221; bundle"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => array:2 [
          0 => "en"
          1 => "es"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "226"
            "paginaFinal" => "236"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "es" => array:1 [
            "titulo" => "Paquete de medidas para la prevenci&#243;n de la neumon&#237;a asociada a la ventilaci&#243;n mec&#225;nica y su aplicaci&#243;n en las UVI espa&#241;olas&#46; El Proyecto &#171;Neumon&#237;a Zero&#187;"
          ]
        ]
        "contieneResumen" => array:2 [
          "en" => true
          "es" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "en" => true
        ]
        "contienePdf" => array:1 [
          "en" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figure 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 3500
                "Ancho" => 2691
                "Tamanyo" => 374093
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Organizational scheme of the &#8220;Zero VAP&#8221; Project&#46; &#40;SEMICYUC&#58; Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias&#46; SEEIUC&#58; Sociedad Espa&#241;ola de Enfermer&#237;a Intensiva y Unidades Coronarias&#41;&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "F&#46; &#193;lvarez Lerma, M&#46; S&#225;nchez Garc&#237;a, L&#46; Lorente, F&#46; Gordo, J&#46;M&#46; A&#241;&#243;n, J&#46; &#193;lvarez, M&#46; Palomar, R&#46; Garc&#237;a, S&#46; Arias, M&#46; V&#225;zquez-Calatayud, R&#46; Jam"
            "autores" => array:11 [
              0 => array:2 [
                "nombre" => "F&#46;"
                "apellidos" => "&#193;lvarez Lerma"
              ]
              1 => array:2 [
                "nombre" => "M&#46;"
                "apellidos" => "S&#225;nchez Garc&#237;a"
              ]
              2 => array:2 [
                "nombre" => "L&#46;"
                "apellidos" => "Lorente"
              ]
              3 => array:2 [
                "nombre" => "F&#46;"
                "apellidos" => "Gordo"
              ]
              4 => array:2 [
                "nombre" => "J&#46;M&#46;"
                "apellidos" => "A&#241;&#243;n"
              ]
              5 => array:2 [
                "nombre" => "J&#46;"
                "apellidos" => "&#193;lvarez"
              ]
              6 => array:2 [
                "nombre" => "M&#46;"
                "apellidos" => "Palomar"
              ]
              7 => array:2 [
                "nombre" => "R&#46;"
                "apellidos" => "Garc&#237;a"
              ]
              8 => array:2 [
                "nombre" => "S&#46;"
                "apellidos" => "Arias"
              ]
              9 => array:2 [
                "nombre" => "M&#46;"
                "apellidos" => "V&#225;zquez-Calatayud"
              ]
              10 => array:2 [
                "nombre" => "R&#46;"
                "apellidos" => "Jam"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S217357271400023X"
          "doi" => "10.1016/j.medine.2013.12.001"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357271400023X?idApp=WMIE"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569114000126?idApp=WMIE"
      "url" => "/02105691/0000003800000004/v1_201404270108/S0210569114000126/v1_201404270108/en/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2173572714000216"
    "issn" => "21735727"
    "doi" => "10.1016/j.medine.2014.04.001"
    "estado" => "S300"
    "fechaPublicacion" => "2014-05-01"
    "aid" => "643"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and SEMICYUC"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "sco"
    "cita" => "Med Intensiva. 2014;38:249-60"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 11885
      "formatos" => array:3 [
        "EPUB" => 187
        "HTML" => 8545
        "PDF" => 3153
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Update in Intensive Care Medicine&#58; Mechanical ventilation</span>"
      "titulo" => "New modes of assisted mechanical ventilation"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "249"
          "paginaFinal" => "260"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Nuevos modos de ventilaci&#243;n asistida"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 2374
              "Ancho" => 3249
              "Tamanyo" => 364993
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Principles of patient&#8211;ventilator interaction&#46; Assisted ventilation has the difficult task of harmonizing the operation of two complex systems&#44; i&#46;e&#46;&#44; patient and ventilator&#8211;each with its own control center and ventilatory pump&#46; The respiratory control system &#40;RCS&#41; is complex&#44; and is composed of an automatic system and a voluntary system&#46; The afferents transmit the stimuli from the sensors &#40;central and peripheral chemoreceptors&#44; stretch receptors and muscle receptors&#41; to the control system&#44; regulating the neural respiratory impulse&#46; The automatic control system emits the efferents &#40;motor neurons&#41; that activate and regulate the muscle pump&#46; The voluntary system in turn can modulate the activity of the automatic system or directly activate the muscle pump&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "F&#46; Suarez-Sipmann"
          "autores" => array:2 [
            0 => array:2 [
              "nombre" => "F&#46;"
              "apellidos" => "Suarez-Sipmann"
            ]
            1 => array:1 [
              "colaborador" => "in representation of the Acute Respiratory Failure Working Group of the SEMICYUC"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0210569113002507"
        "doi" => "10.1016/j.medin.2013.10.008"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569113002507?idApp=WMIE"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000216?idApp=WMIE"
    "url" => "/21735727/0000003800000004/v1_201405150137/S2173572714000216/v1_201405150137/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>"
    "titulo" => "Guidelines for the prevention of ventilator-associated pneumonia and their implementation&#46; The Spanish &#8220;Zero-VAP&#8221; bundle"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "226"
        "paginaFinal" => "236"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "F&#46; &#193;lvarez Lerma, M&#46; S&#225;nchez Garc&#237;a, L&#46; Lorente, F&#46; Gordo, J&#46;M&#46; A&#241;&#243;n, J&#46; &#193;lvarez, M&#46; Palomar, R&#46; Garc&#237;a, S&#46; Arias, M&#46; V&#225;zquez-Calatayud, R&#46; Jam"
        "autores" => array:11 [
          0 => array:3 [
            "nombre" => "F&#46;"
            "apellidos" => "&#193;lvarez Lerma"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          1 => array:4 [
            "nombre" => "M&#46;"
            "apellidos" => "S&#225;nchez Garc&#237;a"
            "email" => array:2 [
              0 => "miguel&#46;sanchez&#64;salud&#46;madrid&#46;org"
              1 => "miguelsanchez&#46;areachip&#64;wanadoo&#46;es"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">¿</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "L&#46;"
            "apellidos" => "Lorente"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "F&#46;"
            "apellidos" => "Gordo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "J&#46;M&#46;"
            "apellidos" => "A&#241;&#243;n"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "J&#46;"
            "apellidos" => "&#193;lvarez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "M&#46;"
            "apellidos" => "Palomar"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">g</span>"
                "identificador" => "aff0035"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "R&#46;"
            "apellidos" => "Garc&#237;a"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">h</span>"
                "identificador" => "aff0040"
              ]
            ]
          ]
          8 => array:3 [
            "nombre" => "S&#46;"
            "apellidos" => "Arias"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
          9 => array:3 [
            "nombre" => "M&#46;"
            "apellidos" => "V&#225;zquez-Calatayud"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">j</span>"
                "identificador" => "aff0050"
              ]
            ]
          ]
          10 => array:3 [
            "nombre" => "R&#46;"
            "apellidos" => "Jam"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">k</span>"
                "identificador" => "aff0055"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:11 [
          0 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital del Mar&#44; Parc de Salut Mar&#44; Barcelona&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Cl&#237;nico San Carlos&#44; Madrid&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario de Canarias&#44; San Crist&#243;bal de La Laguna&#44; Santa Cruz de Tenerife&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario del Henares&#44; Coslada&#44; Madrid&#44; Spain"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Virgen de la Luz&#44; Cuenca&#44; Spain"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
          5 => array:3 [
            "entidad" => "Servicio de Cuidados Intensivos&#44; Hospital Universitario de Fuenlabrada&#44; Fuenlabrada&#44; Madrid&#44; Spain"
            "etiqueta" => "f"
            "identificador" => "aff0030"
          ]
          6 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario Arnau de Vilanova&#44; L&#233;rida&#44; Spain"
            "etiqueta" => "g"
            "identificador" => "aff0035"
          ]
          7 => array:3 [
            "entidad" => "Servicio de Anestesia y Reanimaci&#243;n&#44; Hospital Universitario de Basurto&#44; Bilbao&#44; Vizcaya&#44; Spain"
            "etiqueta" => "h"
            "identificador" => "aff0040"
          ]
          8 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario de Getafe&#44; Getafe&#44; Madrid&#44; Spain"
            "etiqueta" => "i"
            "identificador" => "aff0045"
          ]
          9 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Cl&#237;nica Universidad de Navarra&#44; Pamplona&#44; Navarra&#44; Spain"
            "etiqueta" => "j"
            "identificador" => "aff0050"
          ]
          10 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Centro Hospitalario Parc Taul&#237;&#44; Sabadell&#44; Barcelona&#44; Spain"
            "etiqueta" => "k"
            "identificador" => "aff0055"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Paquete de medidas para la prevenci&#243;n de la neumon&#237;a asociada a la ventilaci&#243;n mec&#225;nica y su aplicaci&#243;n en las UVI espa&#241;olas&#46; El Proyecto &#171;Neumon&#237;a Zero&#187;"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 3500
            "Ancho" => 2691
            "Tamanyo" => 373584
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Organizational scheme of the &#8220;Zero VAP&#8221; Project&#46; &#40;SEMICYUC&#58; Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias&#46; SEEIUC&#58; Sociedad Espa&#241;ola de Enfermer&#237;a Intensiva y Unidades Coronarias&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ventilator-associated pneumonia &#40;VAP&#41; is the most frequent ICU-acquired infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> It is associated with significant increases in the length of stay&#44; healthcare costs and both crude and attributed mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> Therefore&#44; potential functional&#44; mechanical and pharmacological prevention measures of VAP have frequently been investigated&#44; classified and recommended in accordance with updated available evidence and feasibility&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;17</span></a> Questionnaires&#44; however&#44; repeatedly report that knowledge&#44; implementation and adherence to guidelines are low among nurses and physicians working in ICUs internationally&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The Spanish annual April to June ICU National Nosocomial Infection Surveillance Study &#40;Estudio Nacional de Vigilancia de Infecci&#243;n Nosocomial&#44; &#8220;ENVIN&#8221;&#41;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;2</span></a> shows stable VAP incidence densities of approximately 15 episodes per 1000 days of mechanical ventilation for the years 2000&#8211;2009 in more than 100 ICUs&#46; These figures compare negatively with other national surveillance programs&#46; The United States National Healthcare Safety Network reports mean VAP incidence rates of 3&#46;7 for 2006&#8211;2008&#44; from as low as 2&#46;1 in pediatric medical-surgical ICUs to 10&#46;7 episodes per 1&#46;000 days in burn units<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Recently&#44; the implementation of &#8220;bundles&#8221; of effective measures&#44; compared to individual interventions&#44; has been proposed to reduce the incidence of catheter-related bloodstream infections<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and VAP&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In Spain&#44; a highly successful bacteraemia prevention bundle&#44; named &#8220;Zero Bacteraemia&#8221;&#44; was started and implemented by the Spanish Society of Intensive Care Medicine &#40;SEMICYUC&#41; in 2008<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> under the auspices and financial support of the World Health Organization and the Quality Assurance Agency of the Spanish Ministry of Health &#40;QAA&#41;&#46; The &#8220;Zero-VAP&#8221; Project uses the organizational structure and methodology created for &#8220;Zero-Bacteraemia&#8221;&#46; In this article we describe the methods applied to identify the recommendations to be included in the &#8220;Zero-VAP&#8221; bundle and to accomplish implementation in Spanish ICUs&#46; We also refer to the systems used to monitor compliance and to register the data generated during the project and describe the associated quality assurance program&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Methods and design</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Structure and organization</span><p id="par0020" class="elsevierStylePara elsevierViewall">SEMICYUC and the Spanish Society of Intensive Care Nurses &#40;SEEIUC&#41; lead and coordinate the technical aspects of &#8220;Zero-VAP&#8221; by means of a working contract&#46; The QAA hierarchically involves the 17 regional healthcare authorities and the hospital directors of the participating ICUs and promotes the Project through co-financing with the regional healthcare authorities&#44; nation-wide coordination&#44; dissemination and follow-up &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; For every Spanish autonomous region&#44; as well as in every ICU&#44; an intensivist and an intensive care nurse coordinate &#8220;Zero-VAP&#8221; at their respective level&#46; The definitions of the European CDC<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a> for VAP and tracheobronchitis have been adopted and are available in the user&#39;s manual of ENVIN-HELICS&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In brief&#44; the presence of these features suggest VAP&#58; two or more serial chest X-rays or CT scans with a suggestive image for patients with underlying cardiac or pulmonary disease&#44; or one definitive chest X-ray or CT scan in patients without underlying cardiac or pulmonary disease&#44; with fever &#62;38<span class="elsevierStyleHsp" style=""></span>&#176;C and&#47;or leucocytosis &#8805;12&#44;000<span class="elsevierStyleHsp" style=""></span>WBC&#47;mm<span class="elsevierStyleSup">3</span> or leucopenia &#8804;4000<span class="elsevierStyleHsp" style=""></span>WBC&#47;mm<span class="elsevierStyleSup">3</span>&#44; and at least one of the following&#58; &#40;1&#41; new onset purulent sputum or change of character of sputum&#59; &#40;2&#41; cough&#44; dyspnea or tachycardia&#59; &#40;3&#41; suggestive auscultation or &#40;4&#41; worsening gas exchange&#46; VAP episodes were additionally stratified according to the microbiological sampling diagnostic method employed&#46; The target of reduction of VAP to less than 9 episodes per 1000 days of mechanical ventilation was chosen because compared to the period 2000&#8211;2009 and the most recent results it represents reductions of 40&#37; and 25&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A national task force with members of SEMICYUC and SEEIUC selected the prevention measures and will be in charge of the management of the Project&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The VAP prevention bundle&#44; the objectives and tools for implementation and control of &#8220;Zero-VAP&#8221; were presented at a national meeting and subsequently at regional and local meetings&#46; The &#8220;Zero-VAP&#8221; guidelines are an extension of ENVIN-HELICS&#44; which collects epidemiological data from all patients admitted to participating ICUs from April 1st to June 30th yearly since 1994 and does not require ethics committee approval&#46; Viewed as a quality improvement initiative&#44; neither the Spanish Ministry of Health nor the regional healthcare authorities requested evaluation of the project by local or regional ethics committees&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Selection of ventilator-associated pneumonia prevention measures</span><p id="par0035" class="elsevierStylePara elsevierViewall">Thirty-five interventions were derived from published clinical trials&#44; guidelines&#44; systematic reviews and meta-analyses&#46; They were classified as &#8220;functional&#8221;&#44; &#8220;mechanical&#8221; or &#8220;pharmacological&#8221; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and evaluated independently by teams of at least two members of the task force using the Grading of Recommendations Assessment&#44; Development and Evaluation Working Group methodology<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> &#40;<a id="intr0005" class="elsevierStyleInterRef" href="http://www.gradeworkinggroup.org/">http&#58;&#47;&#47;www&#46;gradeworkinggroup&#46;org&#47;</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Inclusion of 8 debated interventions was resolved by quantitative assessment by the 11 members of the panel&#44; considering &#40;1&#41; the quality of the evidence &#40;10 points&#41;&#44; &#40;2&#41; its safety &#40;5 points&#41;&#44; and its feasibility in Spanish ICUs &#40;5 points&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Finally&#44; feasibility and cost criteria were applied&#44; as recommended&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> based on which groups of 7 &#8220;basic mandatory&#8221; and 3 &#8220;highly recommended&#8221; measures &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41; were generated&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surveillance and control of compliance</span><p id="par0040" class="elsevierStylePara elsevierViewall">Several systems for the surveillance of adhesion to the Project and compliance of the proposed measures have been established&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Participation in the web-based &#8220;ENVIN-HELICS&#8221; registry</span>&#46; ICUs are committed to enter data required for calculation of incidence density of VAP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Provision of education and training to healthcare workers &#40;HCW&#41;</span>&#46; Two educational modules about VAP prevention and patient safety&#44; with their corresponding examinations&#44; are freely accessible on-line<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and continuously monitored for number and category of ICU-HCW successfully completing the tests&#46; Coordinators in each unit have access to this registry and report to the regional coordinators&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Evaluation of compliance</span>&#46; The web-based 6-monthly compliance registry consists of 3 quality indicators&#44; which were arbitrarily selected because of the ease of monitoring&#58; &#40;1&#41; cuff pressure control prior to oral hygiene&#44; &#40;2&#41; the use of chlorhexidine for oral hygiene&#44; and &#40;3&#41; the number of monthly meetings and activities related to the Project&#46; The previous registry for &#8220;Zero Bacteremia&#8221;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> remains active&#58; &#40;1&#41; a checklist for the insertion of vascular catheters&#44; &#40;2&#41; chlorhexidine skin disinfection&#44; &#40;3&#41; availability of a vascular catheter insertion cart&#44; &#40;4&#41; achievement of daily objectives&#44; &#40;5&#41; meeting with hospital directors and &#40;6&#41; &#8220;learning from errors&#8221; meetings&#46; Information about how many indicators are accomplished is available on-line&#46; The optional &#8220;highly recommended&#8221; measure&#40;s&#41; implemented at each ICU will be captured from the general database &#40;SDD&#41; and from a structured questionnaire &#40;subglottic aspiration and short course of iv antibiotic&#41; to allow for a separate comparative statistical analysis&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Database</span><p id="par0060" class="elsevierStylePara elsevierViewall">&#8220;Zero VAP&#8221; data are recorded through a specific adaptation of the &#8220;ENVIN-HELICS&#8221; web page &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://hws.vhebron.net/Neumonia-zero/">http&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;Neumonia-zero&#47;</a>&#41;&#46; Participating ICUs record data of patients meeting the definition of VAP&#46; In addition&#44; monthly information about risk factors&#44; including total patient-days and ventilated patient-days&#44; is provided&#46; If a patient develops VAP&#44; a database entry is created with information on demographics&#44; risk factors&#44; severity at ICU admission&#44; underlying conditions&#44; comorbidity&#44; diagnostic criteria&#44; microbiological sampling procedures&#44; etiology and clinical course&#46; Patients entered in the &#8220;ENVIN-HELICS&#8221; surveillance program are recorded automatically in the &#8220;Zero VAP&#8221; database&#44; with no additional intervention being required&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Summary descriptive statistics are available on-line for every individual unit&#44; which may directly access its data on a daily basis&#46; Local results are displayed together with the corresponding regional and national values&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Detailed educational slide presentations for every component of both &#8220;basic mandatory&#8221; and &#8220;highly recommend&#8221; measures can be freely accessed at <a id="intr0015" class="elsevierStyleInterRef" href="http://hws.vhebron.net/Neumonia-zero/">http&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;Neumonia-zero&#47;</a>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Basic mandatory measures</span><p id="par0075" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Education and training in airway management</span> &#40;aspiration of bronchial secretions&#41;&#46; A systematic review including 26 studies<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> suggests that educational interventions are associated with significant reductions in nosocomial infection rates&#44; although a causal relation cannot be established due to limitations in study design&#46; Several studies show significant reductions in VAP incidence after implementation of educational programs<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a> and simple clinical protocols&#44; including emphasis on strict hand hygiene&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Although the quality of evidence for educational interventions for airway management is &#8220;moderate&#8221;&#44; the strength of this recommendation was classified as &#8220;strong&#8221; because of its significant association with the prevention of VAP&#44; no major threats for safety&#44; and low cost of implementation&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The specific care practices taught in the educational program to be implemented at the beginning of the project are freely available at <a id="intr0020" class="elsevierStyleInterRef" href="http://hws.vhebron.net/Neumonia-zero/">http&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;Neumonia-zero&#47;</a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Strict hand hygiene with alcohol solutions before airway management</span>&#46; Observational studies<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> report reductions in nosocomial infection rates and methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MRSA&#41; infection after promoting hand-washing&#46; Hand-washing before and after patient contact and the use of gloves were introduced in 2004 as proven measures for the prevention of VAP and other nosocomial infections&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It is now firmly established as a fundamental component of standard clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The use of gloves does not preclude the obligation of hand-washing with alcohol solutions before and after management of the artificial airway&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Oral hygiene with chlorhexidine</span>&#46; Chlorhexidine has been recommended for MRSA skin decolonization<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#8211;38</span></a> and VAP prevention&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10&#44;15</span></a> Four of 6 meta-analyses<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#8211;44</span></a> show significant reductions of VAP incidence rates with oropharyngeal chlorhexidine&#46; A recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> favors chlorhexidine &#40;OR 0&#46;56&#44; 95&#37;CI 0&#46;44&#8211;0&#46;73&#41;&#44; although 6 of the 10 trials were negative&#46; The variable effect of chlorhexidine seems to be related to its limited microbiological effect&#44; which&#44; while reducing oropharyngeal carriage with <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; leaves Gram-negative colonization largely unaffected&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Efficacy may also be related to the local concentrations of chlorhexidine&#46; A trial administering a high concentration 2&#37; solution showed a significant reduction of VAP&#44; although 10&#37; of patients in the test group developed irritation of the oral mucosa&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Chlorhexidine apparently has no risk of inducing cross-resistance to antibiotics&#46; However&#44; chlorhexidine-resistant strains of MRSA may substitute susceptible strains shortly after initiating routine chlorhexidine application&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a> Up to 63&#37; of European strains actually express plasmid-borne <span class="elsevierStyleItalic">qacA</span>&#47;<span class="elsevierStyleItalic">B</span> genes coding for multidrug efflux pumps&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> which confer chlorhexidine resistance in MRSA&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Oral hygiene with aqueous chlorhexidine solutions &#40;0&#46;12&#8211;2&#37;&#41; should be performed every 8<span class="elsevierStyleHsp" style=""></span>h&#46; Before its application&#44; cuff pressure should be above 20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; Formal training of nurse&#39;s aides&#44; responsible for this procedure in most ICUs&#44; will be done&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Control and maintenance of cuff pressure</span>&#46; Although included in the guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> this recommendation is based on the results of a small single-centre&#44; non-comparative study<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> suggesting that a cuff pressure level below 20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O is associated with an increased risk of VAP in patients not receiving systemic antibiotics&#46; A recent randomized trial&#44; comparing continuous monitoring of cuff pressure with intermittent or non-scheduled measurements&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> did not confirm this association in spite of a significant difference in the incidence of cuff pressures below 20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; The panel considered that routine checks of cuff pressure is a simple low cost standard clinical procedure&#44; also controlling for inappropriately high pressures and should be scheduled at 8<span class="elsevierStyleHsp" style=""></span>h intervals and set at 20&#8211;30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O before oral application of chlorhexidine&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">5&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Semi-recumbent positioning&#46; Avoidance of 0&#176; supine positioning</span>&#46; The physiologic rationale behind semi-recumbent positioning is that it may favor spontaneous ventilation and reduce aspiration of contaminated gastric content&#46; Its effect on VAP prevention has not been validated in unstable patients or patients with increased intra-abdominal pressure&#44; and results of randomized trials vary&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#44;53</span></a> A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> using a random effects model to compensate for significant heterogeneity observed a non-significant reduction in the incidence of VAP &#40;OR 0&#46;59&#44; 95&#37;CI 0&#46;15&#8211;2&#46;35&#41; in patients in a semi-recumbent 45&#176; position&#46; A recent well-conducted randomized trial<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> enrolling 232 patients with tetanus was negative&#44; with 20&#46;8&#37; &#40;39&#46;2 episodes per 1000 days of ventilation&#41; patients developing VAP in supine position and 25&#37; &#40;38&#46;1 episodes&#41; in semi-recumbence &#40;OR 0&#46;79&#44; 95&#37;CI 0&#46;39&#8211;1&#46;57&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;46&#41;&#46; Differing study results prevent establishing a firm recommendation to elevate backrests to 45&#176;&#46; However&#44; it is recommended to avoid 0&#176; supine positioning in patients receiving enteral feeding and with no contraindication&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">6&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Promoting procedures and protocols that safely avoid or reduce duration of mechanical ventilation</span>&#46; Effective interventions aimed at avoiding or shortening duration of endotracheal intubation are associated with reductions of VAP&#46; Therefore&#44; protocols for non-invasive mechanical ventilation &#40;NIMV&#41; in acute exacerbations of chronic obstructive pulmonary disease &#40;COPD&#41;&#44; for weaning or for sedation promoting lower infusion doses or its daily interruption should be available&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">NIMV appears to be associated with reduced mortality and VAP &#40;relative risk 0&#46;29&#44; 95&#37;CI 0&#46;19&#8211;0&#46;45&#41; when used as a weaning strategy in patients with COPD after extubation&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">A recent systematic review<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> suggests that the use of weaning protocols is associated with a reduced duration of mechanical ventilation&#46; However&#44; significant heterogeneity between studies and the absence of data on VAP preclude grading of evidence of this potentially preventive measure&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">To our knowledge&#44; no study evaluating the effect of daily sedation vacation on VAP incidence as end-point has been performed&#46; Two landmark trials evaluating daily interruption of sedation did not mention comparative VAP rates&#44; although both found significant reductions in the duration of mechanical ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">58&#44;59</span></a> Therefore&#44; the quality of the evidence of VAP prevention by reducing sedation could not be appropriately graded&#46; A detailed sedation protocol was deemed to be beyond the scope of the Project&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Based on the available data&#44; the panel decided to issue a generic recommendation for the availability of updated weaning and sedation protocols and for the use of NIMV in selected patient populations&#44; to reduce the duration of mechanical ventilation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">7&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Avoidance of elective changes of ventilator circuits&#44; humidifiers and endotracheal tubes</span>&#46; Planned ventilator circuit changes may increase cost and the risk of VAP and should not be performed&#44; as has already been recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11</span></a> A systematic review<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> confirms that 48<span class="elsevierStyleHsp" style=""></span>h circuit changes compared to 7 days almost double the risk of VAP &#40;OR 1&#46;93&#44; 95&#37;CI 1&#46;08&#8211;3&#46;44&#41;&#46; It is concluded that the practice of planned ventilator circuit changes should be abandoned&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Heat-moisture exchangers &#40;HME&#41; have been suggested to be associated with lower incidence of VAP than heated humidifiers &#40;HH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> A recent meta-analysis does not confirm this effect<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> and&#44; therefore&#44; HH should be reserved for individual cases at increased risk of airway obstruction&#46; The adequate frequency of change of HME has not been established&#46; The results of prospective before-after studies and randomized trials indicate that prolonging the duration of HMEs from 24 to 48<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63&#44;64</span></a> to 5 days&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> and even to 7 days&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> reduces costs and does not increase VAP&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Highly recommended measures</span><p id="par0150" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Selective Decontamination of the Digestive Tract &#40;SDD&#41; or Selective Oropharyngeal Decontamination &#40;SOD&#41;</span>&#46; This intervention aims at the reduction of endogenous infections by preventing or eradicating the aero-digestive carrier state with potentially pathogenic flora&#46; The SDD protocol includes administration of a short 2- to 5-day course of a third generation cephalosporin and topical antibiotics administered as a paste to the oral mucosa and as a solution via nasogastric tube&#46; The topical antimicrobials are non-absorbable to maintain high luminal gut concentrations and prevent the development of resistance&#46; This strategy has no effect on exogenous infections&#44; which are caused by direct inoculation&#44; although it may reduce cross-transmission&#46; SDD is associated with reductions of VAP of approximately 70&#37; in 60 randomized trials and 15 meta-analyses&#46; A recent individual patient meta-analysis<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> calculated an odds ratio of 0&#46;28 &#40;95&#37;CI 0&#46;20&#8211;0&#46;38&#41; for the development of VAP&#46; SDD is also associated with significant reductions in bacteraemia &#40;OR 0&#46;73&#44; 95&#37;CI 0&#46;59&#8211;0&#46;9&#41;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> and mortality &#40;OR 0&#46;75&#44; 95&#37;CI 0&#46;65&#8211;0&#46;87&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> Although concerns about the development of resistance during SDD have been voiced&#44; the most recent and biggest randomized multicentre trials demonstrate significant reductions of incidence rates of multi-drug resistant bacteria &#40;MDR&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#8211;71</span></a> SOD&#44; studied in 9 controlled trials&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> drastically reduces VAP risk &#40;OR 0&#46;17&#44; 95&#37;CI 0&#46;17&#8211;0&#46;43&#41;&#44; although not mortality&#44; or gastro-intestinal carriage with MDR&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#44;71</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The implementation of SDD and SOD requires the collaboration of several hospital departments&#44; such as critical care&#44; microbiology and pharmacy and neither the antimicrobial paste nor the oral solution is commercially available&#46; Therefore&#44; although the panel considered the quality of the evidence favoring SDD to be &#8220;high&#8221; and strongly recommends its use&#44; it was not categorized as a basic mandatory measure&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In order to facilitate its implementation&#44; the instructions for manufacture&#44; administration and surveillance are provided&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">2&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Continuous aspiration of subglottic secretions &#40;CASS&#41;</span>&#46; A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> found that CASS significantly reduces early-onset VAP &#40;EO-VAP&#41; in patients exceeding 3 days of intubation &#40;risk ratio for all episodes 0&#46;51&#44; 95&#37;CI 0&#46;37&#8211;0&#46;71&#44; for EO-VAP 0&#46;38&#44; 95&#37;CI 0&#46;16&#8211;0&#46;88&#41;&#44; although it does not prevent colonization or infection of the respiratory tract with <span class="elsevierStyleItalic">Enterobacteriaceae</span> or <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#46; The duration of mechanical ventilation and that of ICU stay were reduced by 2 days &#40;95&#37;CI 1&#46;7&#8211;2&#46;3&#41; and 3 days &#40;95&#37;CI 2&#46;1&#8211;3&#46;9&#41;&#44; respectively&#44; with no effect on mortality&#46; A recent randomized trial in patients undergoing a major heart surgery<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> was negative&#46; A post hoc sub-group analysis of patients ventilated more than 48<span class="elsevierStyleHsp" style=""></span>h found significant reductions of cumulative incidence of VAP &#40;26&#46;7&#37; vs&#46; 47&#46;5&#37;&#44; relative risk 0&#46;40&#44; 95&#37;CI 0&#46;16&#8211;0&#46;99&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#44; ICU length-of-stay &#40;7 vs&#46; 16&#46;5 days&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and antibiotic use&#44; with no effect on mortality&#46; No adverse events attributed to CASS have been reported in humans&#44; although evidence of widespread injury to tracheal mucosa and submucosa was documented after 72<span class="elsevierStyleHsp" style=""></span>h of CASS in sheep&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">As for SDD&#44; CASS is not widely available and expensive&#46; Instructions for its use are provided&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">3&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Short course &#40;2&#8211;3 days&#41; of systemic antibiotic therapy</span>&#46; A short course of intravenous cephalosporin was added to topical antibiotics in the SDD protocol in order to prevent primary endogenous&#44; mainly respiratory tract&#44; infection in severe trauma patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">76&#44;77</span></a> This measure has been evaluated separately for the prevention of VAP&#44; without concomitant administration of topical antimicrobials&#44; and was therefore included in the bundle for those ICUs not implementing the complete SDD protocol&#46;</p></li></ul></p><p id="par0185" class="elsevierStylePara elsevierViewall">Patients with decreased level of consciousness are particularly at a high risk of primary endogenous VAP&#44; typically including severe trauma&#44; severe head trauma&#44; stroke&#44; cardiac arrest and metabolic or drug-related central nervous system depression&#46; A small randomized controlled trial<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> showed a significant reduction of the incidence of VAP from 36&#37; to 18&#37; associated with the administration of only 2 doses of cefuroxime 1&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;12<span class="elsevierStyleHsp" style=""></span>h&#46; In a double-blind randomized multicentre trial&#44; 3 doses of ceftriaxone 2<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h were associated with a significant reduction of primary endogenous VAP from 51&#46;3&#37; to 14&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> Intravenous antibiotics have shown to be protective<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#44;80</span></a> and are therefore recommended&#44; similar to surgical prophylaxis&#44; in the aforementioned patient populations&#44; although they do not reduce late infections&#44; morbidity or mortality&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In patients with decreased level of consciousness&#44; a short 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h course of intravenous cefuroxime&#44; ceftriaxone or amoxicillin-clavulanate should be considered&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0195" class="elsevierStylePara elsevierViewall">The last decade has witnessed the publication of rigorous and comprehensive guidelines for the prevention of VAP&#44; generated with ever-improving and transparent methodologies&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10&#44;49&#44;9&#44;11&#8211;15</span></a> which have provided detailed reviews of the literature and thoughtful recommendations&#46; The Spanish &#8220;Zero VAP&#8221; Project&#44; developed under the leadership of SEMICYUC&#44; has several additional differential features&#44; which in our opinion extends the value of this initiative beyond that of its 7 &#8220;basic&#8221; and 3 &#8220;highly recommended&#8221; or other published &#8220;conventional&#8221; guidelines&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Beyond the usual physician-led recommendations&#44; this project was developed from its earliest phases in collaboration with the Spanish critical care nurses &#40;SEEIUC&#41;&#44; who participated actively in all theoretical and practical aspects of its design&#44; training&#44; implementation&#44; adherence&#44; compliance&#44; quality assurance and coordination&#46; The active role of the nurses and their identification with the initiative were considered to be an essential element for success&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">&#8220;Zero-VAP&#8221; is an interventional program incorporated into a firmly established observational ICU infection surveillance program&#44; ENVIN-HELICS&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which the Working Group for Infectious Diseases of SEMICYUC initiated in 1994&#46; ENVIN-HELICS yearly collects data from ICU patients staying<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>h and who are admitted during the surveillance period&#44; which spans from April 1st to June 30th&#46; The ever increasing number of participating ICUs reached 173 in 2012&#46; The huge amount of epidemiological data and surveillance experience accumulated over 18 years in 150&#44;000 patients by Spanish intensivists and critical care nurses constitute a solid historical control group providing the adequate baseline reference data&#46; &#8220;Zero-VAP&#8221; may therefore be viewed as a huge&#44; multicentre&#44; &#8220;before-after&#8221; study&#44; where the efficacy of a VAP prevention bundle is prospectively evaluated&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The establishment of an organizational structure and contractual commitment involving the Spanish Ministry of Health&#44; regional authorities&#44; hospital directors&#44; and regional and site medical and nurse coordinators is another differential characteristic of &#8220;Zero-VAP&#8221;&#44; with the objective to guarantee continued adherence and quality&#46; In addition&#44; continuous monitoring of compliance will also allow validating the prevention package and some of its individual measures&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Compared to conventional guidelines&#44; &#8220;Zero-VAP&#8221; is a bundle of interventions with a pre-defined objective&#46; The reduction of the national VAP incidence rate by 25&#37; and to less than 9 episodes per 1000 days of mechanical ventilation is a simple and clear quantitative target&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Finally&#44; the validation for efficacy and safety of expert recommendations in &#8220;real life&#8221; situations&#44; even if these are produced by the best of methodologies&#44; seems to be becoming more and more important&#46; It may even be argued that future guidelines should be accompanied by evaluation for adequacy and safety&#44; i&#46;e&#46; internal validity&#44; before widespread implementation of recommendations&#46; Performance of randomized trials before implementation of guidelines has recently been proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> In addition&#44; the results of implementing recommendations&#44; i&#46;e&#46; external validity&#44; should ideally be assessable on a continuous basis&#44; similar to phase IV or post-marketing studies of new antimicrobial compounds&#44; thus allowing for early detection of adverse outcomes&#46; &#8220;Zero-VAP&#8221;&#44; through its continuous on-line recording of results and incorporated patient safety and quality improvement program&#44; has efficient incorporated tools to detect and correct errors and to implement modifications or improvements&#44; thereby also guaranteeing future adherence to recommendations&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The weaknesses of &#8220;Zero-VAP&#8221; are related to the &#8220;study&#8221; design and to the absence of site monitoring&#46; Compared to an ideal multicentre&#44; randomized&#44; control trial&#44; the current project has only a historic control group&#44; and confounding variables cannot be definitively excluded&#46; Also&#44; although pre-defined diagnostic criteria exist&#44; underreporting of VAP episodes may start to occur if during the project&#44; candidate VAP episodes are evaluated with stricter criteria than in previous practice&#46; Although a desirable &#8220;fringe benefit&#8221; of the project&#44; this effect may falsely improve the results of implementation of the VAP prevention bundle&#46; Unfortunately&#44; the financial support of the project does not cover site monitoring to detect VAP episodes that are not reported but treated as such with antimicrobials&#46; Monitoring of more than 200 ICUs would require allocation of important economic resources&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In summary&#44; we present &#8220;Zero-VAP&#8221;&#44; the Spanish national VAP prevention bundle&#44; with its organizational structure involving several levels of the healthcare administration&#44; and provide a detailed description of the methodology used for selecting the components of the bundle&#46; Online tools put in place facilitate implementation and adherence and measure compliance and the effect of the bundle on the incidence of VAP in Spanish ICUs&#46; &#8220;Zero-VAP&#8221; also promotes the development of a culture of safety assurance in ICUs&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0235" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleGrantSponsor" id="gs0005">Spanish Ministry of Health</span> provided financial support for the meetings of the task force&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have no competing interests&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:2 [
          "identificador" => "xres339236"
          "titulo" => array:4 [
            0 => "Abstract"
            1 => "Background"
            2 => "Methods&#47;design"
            3 => "Discussion"
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec320810"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres339237"
          "titulo" => array:4 [
            0 => "Resumen"
            1 => "Antecedentes"
            2 => "M&#233;todos&#47;dise&#241;o"
            3 => "Debate"
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec320811"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Background"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Methods and design"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Structure and organization"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Selection of ventilator-associated pneumonia prevention measures"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Surveillance and control of compliance"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Database"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Basic mandatory measures"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Highly recommended measures"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Funding"
        ]
        8 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflicts of interest"
        ]
        9 => array:2 [
          "identificador" => "xack82380"
          "titulo" => "Acknowledgements"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-11-11"
    "fechaAceptado" => "2013-12-16"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec320810"
          "palabras" => array:6 [
            0 => "Ventilator-associated pneumonia"
            1 => "Intensive care unit"
            2 => "Mechanical ventilation"
            3 => "Prevention bundle"
            4 => "Guidelines"
            5 => "Safety assurance"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec320811"
          "palabras" => array:6 [
            0 => "Neumon&#237;a asociada a la ventilaci&#243;n mec&#225;nica"
            1 => "Unidad de cuidados intensivos"
            2 => "Ventilaci&#243;n mec&#225;nica"
            3 => "Haz de prevenci&#243;n"
            4 => "Directrices"
            5 => "Control de la seguridad"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#8220;Zero-VAP&#8221; is a proposal for the implementation of a simultaneous multimodal intervention in Spanish intensive care units &#40;ICU&#41; consisting of a bundle of ventilator-associated pneumonia &#40;VAP&#41; prevention measures&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods&#47;design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An initiative of the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses&#44; the project is supported by the Spanish Ministry of Health&#44; and participation is voluntary&#46; In addition to guidelines for VAP prevention&#44; the &#8220;Zero-VAP&#8221; Project incorporates an integral patient safety program and continuous online validation of the application of the bundle&#46; For the latter&#44; VAP episodes and participation indices are entered into the web-based Spanish ICU Infection Surveillance Program &#8220;ENVIN-HELICS&#8221; database&#44; which provides continuous information about local&#44; regional and national VAP incidence rates&#46; Implementation of the guidelines aims at the reduction of VAP to less than 9 episodes per 1000 days of mechanical ventilation&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 35 preventive measures were initially selected&#46; A task force of experts used the Grading of Recommendations&#44; Assessment&#44; Development and Evaluation Working Group methodology to generate a list of 7 basic &#8220;mandatory&#8221; recommendations &#40;education and training in airway management&#44; strict hand hygiene for airway management&#44; cuff pressure control&#44; oral hygiene with chlorhexidine&#44; semi-recumbent positioning&#44; promoting measures that safely avoid or reduce time on ventilator&#44; and discouraging scheduled changes of ventilator circuits&#44; humidifiers and endotracheal tubes&#41; and 3 additional &#8220;highly recommended&#8221; measures &#40;selective decontamination of the digestive tract&#44; aspiration of subglottic secretions&#44; and a short course of iv antibiotic&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We present the Spanish VAP prevention guidelines and describe the methodology used for the selection and implementation of the recommendations and the organizational structure of the project&#46; Compared to conventional guideline documents&#44; the associated safety assurance program&#44; the online data recording and compliance control systems&#44; as well as the existence of a pre-defined objective are the distinct features of &#8220;Zero VAP&#8221;&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0030">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#171;Neumon&#237;a Zero&#187; es una propuesta de aplicaci&#243;n de una intervenci&#243;n multimodal simult&#225;nea en las unidades de cuidados intensivos espa&#241;olas que consiste en un paquete de medidas preventivas de la neumon&#237;a asociada a la ventilaci&#243;n mec&#225;nica &#40;NAVM&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0035">M&#233;todos&#47;dise&#241;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se trata de una iniciativa de las sociedades espa&#241;olas de Medicina Intensiva y Enfermer&#237;a Intensiva&#46; El proyecto cuenta con el apoyo del Ministerio de Sanidad y la participaci&#243;n es voluntaria&#46; Adem&#225;s de las directrices para la prevenci&#243;n de la NAVM&#44; el proyecto &#171;Neumon&#237;a Zero&#187; incluye un programa integral de seguridad del paciente y una validaci&#243;n continua &#171;online&#187; de la aplicaci&#243;n de las medidas&#46; Para ello se introducen los episodios de NAVM y los &#237;ndices de participaci&#243;n en la base de datos en red del programa &#171;ENVIN-HELICS&#187; de vigilancia de las infecciones en las unidades de cuidados intensivos espa&#241;olas&#44; que ofrece informaci&#243;n continua acerca de las tasas de incidencia de NAVM a nivel local&#44; auton&#243;mico y nacional&#46; La aplicaci&#243;n de &#171;Neumon&#237;a Zero&#187; pretende reducir las NAVM a menos de 9 episodios por cada 1&#46;000 d&#237;as de ventilaci&#243;n mec&#225;nica&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Inicialmente&#44; se seleccionaron 35 medidas de prevenci&#243;n&#46; Un grupo de expertos utiliz&#243; la metodolog&#237;a del Grading of Recommendations&#44; Assessment&#44; Development and Evaluation Working Group para crear una lista de 7 recomendaciones b&#225;sicas &#171;obligatorias&#187; &#40;formaci&#243;n y entrenamiento en el manejo de la v&#237;a a&#233;rea&#44; higiene estricta de manos en el manejo de la v&#237;a a&#233;rea&#44; control de la presi&#243;n del neumotaponamiento&#44; higiene bucal con clorhexidina&#44; posici&#243;n semiincorporada&#44; fomento de medidas que de forma segura eviten o reduzcan la duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; y desaconsejar los cambios programados de tubuladuras&#44; humidificadores y tubos endotraqueales&#41; y 3 medidas adicionales &#171;muy recomendables&#187; &#40;descontaminaci&#243;n selectiva del tubo digestivo&#44; aspiraci&#243;n de las secreciones subgl&#243;ticas y un breve curso de antibi&#243;ticos intravenosos&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Debate</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Presentamos las directrices espa&#241;olas para la prevenci&#243;n de la NAVM y describimos la metodolog&#237;a utilizada para seleccionar y aplicar las recomendaciones y la estructura organizativa del proyecto&#46; En comparaci&#243;n con recomendaciones convencionales&#44; el programa de seguridad asociado&#44; el registro de datos &#171;online&#187; y los sistemas de control del cumplimiento&#44; adem&#225;s de la existencia de un objetivo predefinido&#44; son caracter&#237;sticas distintivas de &#171;Neumon&#237;a Zero&#187;&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 3500
            "Ancho" => 2691
            "Tamanyo" => 373584
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Organizational scheme of the &#8220;Zero VAP&#8221; Project&#46; &#40;SEMICYUC&#58; Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias&#46; SEEIUC&#58; Sociedad Espa&#241;ola de Enfermer&#237;a Intensiva y Unidades Coronarias&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Functional</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Semi-recumbent position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Strict hand hygiene with alcohol-based gels or solutions before airway management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Education and training in aspiration of bronchial secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Daily sedation vacation and assessment of weaning and extubation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Availability of weaning protocols&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; Early tracheostomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; Non-invasive mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>8&#46; Microbiological surveillance of cross-contamination and infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>9&#46; Instillation of normal saline prior to endotracheal suctioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>10&#46; Ventilator tubing change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>11&#46; Route of endotracheal intubation&#46; Orotracheal vs&#46; nasotracheal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>12&#46; Type of airway humidification&#46; Preference of heat moisture exchanger or heated humidifier&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>13&#46; Physiotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>14&#46; Positive end-expiratory airway pressure &#40;PEEP&#41; of 5&#8211;8<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O vs&#46; Zero end-expiratory pressure &#40;ZEEP&#41; in patients without lung injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>15&#46; Enteral feeding&#58; route of administration and gastric residual volumes&#46; Use of prokinetics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Mechanical</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Endotracheal tube cuff pressure monitoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Subglottic secretion drainage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Polyurethane-cuffed endotracheal tubes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Polyurethane-cuffed endotracheal tubes with subglottic secretion drainage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Silver-coated endotracheal tubes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; High-volume&#44; low-pressure endotracheal tube cuff&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; Small caliber feeding tubes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>8&#46; Aspiration of tracheobronchial secretions with closed vs&#46; open systems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>9&#46; Endotracheal tube biofilm removal device &#40;Mucus Shaver<span class="elsevierStyleSup">&#174;</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>10&#46; Kinetic bed therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>11&#46; Airway filters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>12&#46; Water-soluble gel lubrication of the endotracheal tube&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>13&#46; Tooth brushing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pharmacological</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Selective decontamination of the digestive tract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Selective oropharyngeal decontamination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Short course of intravenous antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Oral hygiene with chlorhexidine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Nebulized antibiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; Antibiotic cycling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; Probiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab500919.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Classification of VAP prevention methods&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Quality of evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">High</span>&#46; Further research is very unlikely to change our confidence in the estimate of effect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Moderate</span>&#46; Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Low</span>&#46; Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Very low</span>&#46; Any estimate of effect is very uncertain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Degree of recommendation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Strong</span>&#46; Indicating a judgment that most well informed people would make&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Weak</span>&#46; Indicating a judgment that a majority of well-informed people would make but a substantial minority would not&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab500921.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Definitions of quality of evidence and category of recommendation according to the Grading of Recommendations Assessment&#44; Development and Evaluation Working Group&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;2</span></a><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Efficacy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Adverse events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Feasibility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aspiration of subglottic secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid filter and tubing changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">171&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Semi-recumbent positioning&#46; Avoid 0&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Monitoring and control of cuff pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral hygiene with chlorhexidine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">163&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SDD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SOD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Short course of intravenous antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab500922.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Mean individual score of measures categorized as &#8220;strong&#8221; recommendation&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Quality of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Basic mandatory</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Education and training in appropriate airway management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Strict hand hygiene for airway management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Cuff pressure control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Oral hygiene with chlorhexidine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Semi-recumbent positioning&#46; Avoid 0&#176;&#44; if possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; Promote procedures and protocols which safely avoid or reduce time on ventilator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; Avoid scheduled change of ventilator circuit&#44; humidifiers and endotracheal tubes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Highly recommended measures</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Selective Decontamination of the Digestive Tract or Selective Decontamination of the Oropharynx&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Aspiration of subglottic secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Short course of intravenous antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab500920.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Quality of evidence of individual components of the VAP prevention bundle&#46; All interventions were categorized as &#8220;highly recommended&#8221;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:81 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "National Healthcare Safety Network &#40;NHSN&#41; report&#58; data summary for 2006 through 2008&#44; issued December 2009"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;R&#46; Edwards"
                            1 => "K&#46;D&#46; Peterson"
                            2 => "Y&#46; Mu"
                            3 => "S&#46; Banerjee"
                            4 => "K&#46; Allen-Bridson"
                            5 => "G&#46; Morrell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajic.2009.10.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Infect Control"
                        "fecha" => "2009"
                        "volumen" => "37"
                        "paginaInicial" => "783"
                        "paginaFinal" => "805"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20004811"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology and impact of nosocomial infections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46;M&#46; Olaechea"
                            1 => "J&#46; Insausti"
                            2 => "A&#46; Blanco"
                            3 => "P&#46; Luque"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2009.11.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2010"
                        "volumen" => "34"
                        "paginaInicial" => "256"
                        "paginaFinal" => "267"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20096484"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Estudio Nacional de Vigilancia de Infecci&#243;n Nosocomial en UCI &#40;ENVIN-UCI&#41; 2001&#8211;2009"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2012"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nosocomial infection&#44; length of stay&#44; and time-dependent bias"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Beyersmann"
                            1 => "T&#46; Kneib"
                            2 => "M&#46; Schumacher"
                            3 => "P&#46; Gastmeier"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/596020"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2009"
                        "volumen" => "30"
                        "paginaInicial" => "273"
                        "paginaFinal" => "276"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19193018"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46; Chastre"
                            1 => "J&#46;Y&#46; Fagon"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.165.7.2105078"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2002"
                        "volumen" => "165"
                        "paginaInicial" => "867"
                        "paginaFinal" => "903"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11934711"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortality&#44; attributable mortality&#44; and clinical events as end points for clinical trials of ventilator-associated pneumonia and hospital-acquired pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;G&#46; Muscedere"
                            1 => "A&#46; Day"
                            2 => "D&#46;K&#46; Heyland"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/653060"
                      "Revista" => array:7 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2010"
                        "volumen" => "51"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "S120"
                        "paginaFinal" => "S125"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20597661"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical outcomes of health-care-associated infections and antimicrobial resistance in patients admitted to European intensive-care units&#58; a cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;L&#46; Lambert"
                            1 => "C&#46; Suetens"
                            2 => "A&#46; Savey"
                            3 => "M&#46; Palomar"
                            4 => "M&#46; Hiesmayr"
                            5 => "I&#46; Morales"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(10)70258-9"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "30"
                        "paginaFinal" => "38"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21126917"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia&#46; European Task Force on ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Torres"
                            1 => "J&#46; Carlet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2001"
                        "volumen" => "17"
                        "paginaInicial" => "1034"
                        "paginaFinal" => "1045"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11488306"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for preventing health-care-associated pneumonia&#44; 2003&#58; recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "O&#46;C&#46; Tablan"
                            1 => "L&#46;J&#46; Anderson"
                            2 => "R&#46; Besser"
                            3 => "C&#46; Bridges"
                            4 => "R&#46; Hajjeh"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "MMWR Recomm Rep"
                        "fecha" => "2004"
                        "volumen" => "53"
                        "numero" => "RR-3"
                        "paginaInicial" => "1"
                        "paginaFinal" => "36"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15841069"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Dodek"
                            1 => "S&#46; Keenan"
                            2 => "D&#46; Cook"
                            3 => "D&#46; Heyland"
                            4 => "M&#46; Jacka"
                            5 => "L&#46; Hand"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2004"
                        "volumen" => "141"
                        "paginaInicial" => "305"
                        "paginaFinal" => "313"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15313747"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the management of hospital-acquired pneumonia in the UK&#58; report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46;G&#46; Masterton"
                            1 => "A&#46; Galloway"
                            2 => "G&#46; French"
                            3 => "M&#46; Street"
                            4 => "J&#46; Armstrong"
                            5 => "E&#46; Brown"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/jac/dkn162"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Antimicrob Chemother"
                        "fecha" => "2008"
                        "volumen" => "62"
                        "paginaInicial" => "5"
                        "paginaFinal" => "34"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18445577"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia&#58; prevention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Muscedere"
                            1 => "P&#46; Dodek"
                            2 => "S&#46; Keenan"
                            3 => "R&#46; Fowler"
                            4 => "D&#46; Cook"
                            5 => "D&#46; Heyland"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2007.11.014"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2008"
                        "volumen" => "23"
                        "paginaInicial" => "126"
                        "paginaFinal" => "137"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18359430"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Strategies to prevent ventilator-associated pneumonia in acute care hospitals"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;E&#46; Coffin"
                            1 => "M&#46; Klompas"
                            2 => "D&#46; Classen"
                            3 => "K&#46;M&#46; Arias"
                            4 => "K&#46; Podgorny"
                            5 => "D&#46;J&#46; Anderson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/591062"
                      "Revista" => array:7 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2008"
                        "volumen" => "29"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "S31"
                        "paginaFinal" => "S40"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18840087"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Defining&#44; treating and preventing hospital acquired pneumonia&#58; European perspective"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Torres"
                            1 => "S&#46; Ewig"
                            2 => "H&#46; Lode"
                            3 => "J&#46; Carlet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-008-1336-9"
                      "Revista" => array:7 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2009"
                        "volumen" => "35"
                        "paginaInicial" => "9"
                        "paginaFinal" => "29"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18989656"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109701015546"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A European care bundle for prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Rello"
                            1 => "H&#46; Lode"
                            2 => "G&#46; Cornaglia"
                            3 => "R&#46; Masterton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-010-1841-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2010"
                        "volumen" => "36"
                        "paginaInicial" => "773"
                        "paginaFinal" => "780"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20237759"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New issues and controversies in the prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Lorente"
                            1 => "S&#46; Blot"
                            2 => "J&#46; Rello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.201001-0081CI"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2010"
                        "volumen" => "182"
                        "paginaInicial" => "870"
                        "paginaFinal" => "876"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20448095"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the management of adults with hospital-acquired&#44; ventilator-associated&#44; and healthcare-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "American Thoracic Society &#40;ATS&#41; and Infectious Diseases Society of America &#40;IDSA&#41;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200405-644ST"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2005"
                        "volumen" => "171"
                        "paginaInicial" => "388"
                        "paginaFinal" => "416"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15699079"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Ricart"
                            1 => "C&#46; Lorente"
                            2 => "E&#46; Diaz"
                            3 => "M&#46;H&#46; Kollef"
                            4 => "J&#46; Rello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000094226.05094.AA"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "31"
                        "paginaInicial" => "2693"
                        "paginaFinal" => "2696"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nurses&#8217; implementation of guidelines for ventilator-associated pneumonia from the Centers for Disease Control and Prevention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Crit Care"
                        "fecha" => "2007"
                        "volumen" => "16"
                        "paginaInicial" => "28"
                        "paginaFinal" => "36"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence-based guidelines for the prevention of ventilator-associated pneumonia&#58; results of a knowledge test among European intensive care nurses"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2008.06.027"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2008"
                        "volumen" => "70"
                        "paginaInicial" => "180"
                        "paginaFinal" => "185"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An intervention to decrease catheter-related bloodstream infections in the ICU"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa061115"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2006"
                        "volumen" => "355"
                        "paginaInicial" => "2725"
                        "paginaFinal" => "2732"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Study of device use adjusted rates in health care-associated infections after implementation of bundles in a closed-model medical intensive care unit"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2009.06.016"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2010"
                        "volumen" => "25"
                        "paginaInicial" => "174"
                        "paginaFinal" => "178"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of a National Multimodal Intervention to Prevent Catheter-Related Bloodstream Infection in the ICU&#58; The Spanish Experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/CCM.0b013e3182923622"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2013"
                        "volumen" => "41"
                        "paginaInicial" => "2364"
                        "paginaFinal" => "2372"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Surveillance of Nosocomial Infections in Intensive Care Units&#46; Hospital in Europe Link for Infection Control through Sureveillance &#40;HELICS&#41;"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2013"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Should the diagnosis of ventilator associated pneumonia be improved&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2011.08.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2011"
                        "volumen" => "35"
                        "paginaInicial" => "578"
                        "paginaFinal" => "582"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Concordance between European and US case definitions of healthcare-associated infections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/2047-2994-1-28"
                      "Revista" => array:5 [
                        "tituloSerie" => "Antimicrob Resist Infect Control"
                        "fecha" => "2012"
                        "volumen" => "1"
                        "paginaInicial" => "28"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Grading quality of evidence and strength of recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.328.7454.1490"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2004"
                        "volumen" => "328"
                        "paginaInicial" => "1490"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "GRADE&#58; an emerging consensus on rating quality of evidence and strength of recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.39489.470347.AD"
                      "Revista" => array:6 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2008"
                        "volumen" => "336"
                        "paginaInicial" => "924"
                        "paginaFinal" => "926"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incorporating considerations of resources use into grading recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.39504.506319.80"
                      "Revista" => array:6 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2008"
                        "volumen" => "336"
                        "paginaInicial" => "1170"
                        "paginaFinal" => "1173"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Educational interventions for prevention of healthcare-associated infection&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/CCM.0B013E318165FAF3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2008"
                        "volumen" => "36"
                        "paginaInicial" => "933"
                        "paginaFinal" => "940"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reducing ventilator-associated pneumonia rates through a staff education programme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2004.03.002"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2004"
                        "volumen" => "57"
                        "paginaInicial" => "223"
                        "paginaFinal" => "227"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673602074421"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000029194.64089.0B"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2002"
                        "volumen" => "30"
                        "paginaInicial" => "2407"
                        "paginaFinal" => "2412"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/BF03016535"
                      "Revista" => array:6 [
                        "tituloSerie" => "Can J Anaesth"
                        "fecha" => "2005"
                        "volumen" => "52"
                        "paginaInicial" => "535"
                        "paginaFinal" => "541"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of a hospital-wide programme to improve compliance with hand hygiene&#46; Infection Control Programme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2000"
                        "volumen" => "356"
                        "paginaInicial" => "1307"
                        "paginaFinal" => "1312"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109703009252"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Surveillance and control of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> in Spanish hospitals&#46; A GEIH-SEIMC and SEMPSPH consensus document"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2008"
                        "volumen" => "26"
                        "paginaInicial" => "285"
                        "paginaFinal" => "298"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection&#58; 2009 Update by the Infectious Diseases Society of America"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/599376"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2009"
                        "volumen" => "49"
                        "paginaInicial" => "1"
                        "paginaFinal" => "45"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of daily chlorhexidine bathing on hospital-acquired infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1113849"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2013"
                        "volumen" => "368"
                        "paginaInicial" => "533"
                        "paginaFinal" => "542"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Targeted versus universal decolonization to prevent ICU infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1207290"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2013"
                        "volumen" => "368"
                        "paginaInicial" => "2255"
                        "paginaFinal" => "2265"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral hygiene with chlorhexidine in preventing pneumonia associated with mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Bras Pneumol"
                        "fecha" => "2008"
                        "volumen" => "34"
                        "paginaInicial" => "707"
                        "paginaFinal" => "714"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of ventilator-associated pneumonia&#58; analysis of studies published since 2004"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2007.06.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2007"
                        "volumen" => "67"
                        "paginaInicial" => "1"
                        "paginaFinal" => "8"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Topical chlorhexidine for prevention of ventilator-associated pneumonia&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000253395.70708.AC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2007"
                        "volumen" => "35"
                        "paginaInicial" => "595"
                        "paginaFinal" => "602"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized controlled trial and meta-analysis of oral decontamination with 2&#37; chlorhexidine solution for the prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/526438"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2008"
                        "volumen" => "29"
                        "paginaInicial" => "131"
                        "paginaFinal" => "136"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral hygiene with chlorhexidine on the prevention of ventilator-associated pneumonia in intubated patients&#58; a systematic review of randomized clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2010"
                        "volumen" => "135"
                        "paginaInicial" => "491"
                        "paginaFinal" => "497"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of ventilator-associated pneumonia with oral antiseptics&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(11)70127-X"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "845"
                        "paginaFinal" => "854"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/cc7967"
                      "Revista" => array:5 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2009"
                        "volumen" => "13"
                        "paginaInicial" => "R117"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An outbreak in an intensive care unit of a strain of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> sequence type 239 associated with an increased rate of vascular access device-related bacteremia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/511034"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2007"
                        "volumen" => "44"
                        "paginaInicial" => "493"
                        "paginaFinal" => "501"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> in an intensive care unit"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/648717"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2010"
                        "volumen" => "50"
                        "paginaInicial" => "210"
                        "paginaFinal" => "217"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Distribution of the antiseptic resistance genes qacA&#44; qacB and qacC in 497 methicillin-resistant and -susceptible European isolates of <span class="elsevierStyleItalic">Staphylococcus aureus</span>"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Antimicrob Chemother"
                        "fecha" => "2001"
                        "volumen" => "47"
                        "paginaInicial" => "896"
                        "paginaFinal" => "897"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Guidelines for the management of adults with hospital-acquired&#44; ventilator-associated&#44; and healthcare-associated pneumonia"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200405-644ST"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2005"
                        "volumen" => "171"
                        "paginaInicial" => "388"
                        "paginaFinal" => "416"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pneumonia in intubated patients&#58; role of respiratory airway care"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.154.1.8680665"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1996"
                        "volumen" => "154"
                        "paginaInicial" => "111"
                        "paginaFinal" => "115"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109704025069"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000266686.95843.7D"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2007"
                        "volumen" => "35"
                        "paginaInicial" => "1543"
                        "paginaFinal" => "1549"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients&#58; a randomised trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(98)12251-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1999"
                        "volumen" => "354"
                        "paginaInicial" => "1851"
                        "paginaFinal" => "1858"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia&#58; a randomized study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "34"
                        "paginaInicial" => "396"
                        "paginaFinal" => "402"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of patient position on the incidence of ventilator-associated pneumonia&#58; a meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2008.09.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2009"
                        "volumen" => "24"
                        "paginaInicial" => "515"
                        "paginaFinal" => "522"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Semi-recumbent body position fails to prevent healthcare-associated pneumonia in Vietnamese patients with severe tetanus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.trstmh.2011.10.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Trans R Soc Trop Med Hyg"
                        "fecha" => "2012"
                        "volumen" => "106"
                        "paginaInicial" => "90"
                        "paginaFinal" => "97"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2010"
                        "paginaInicial" => "CD004127"
                        "itemHostRev" => array:3 [
                          "pii" => "S073510970402039X"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2010"
                        "paginaInicial" => "CD006904"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM200005183422002"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2000"
                        "volumen" => "342"
                        "paginaInicial" => "1471"
                        "paginaFinal" => "1477"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care &#40;Awakening and Breathing Controlled trial&#41;&#58; a randomised controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(08)60105-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2008"
                        "volumen" => "371"
                        "paginaInicial" => "126"
                        "paginaFinal" => "134"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of ventilator circuit changes on ventilator-associated pneumonia&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2010"
                        "volumen" => "55"
                        "paginaInicial" => "467"
                        "paginaFinal" => "474"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of heat and moisture exchangers in preventing ventilator-associated pneumonia&#58; meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-004-2431-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2005"
                        "volumen" => "31"
                        "paginaInicial" => "5"
                        "paginaFinal" => "11"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of passive humidification on clinical outcomes of mechanically ventilated patients&#58; a meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2007"
                        "volumen" => "35"
                        "paginaInicial" => "2843"
                        "paginaFinal" => "2851"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Changing heat and moisture exchangers every 48<span class="elsevierStyleHsp" style=""></span>hours does not increase the incidence of nosocomial pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/501631"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "1999"
                        "volumen" => "20"
                        "paginaInicial" => "347"
                        "paginaFinal" => "349"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Changing heat and moisture exchangers every 48<span class="elsevierStyleHsp" style=""></span>hours rather than 24<span class="elsevierStyleHsp" style=""></span>hours does not affect their efficacy and the incidence of nosocomial pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.152.5.7582295"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1995"
                        "volumen" => "152"
                        "numero" => "5 Pt 1"
                        "paginaInicial" => "1562"
                        "paginaFinal" => "1569"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prolonged use of heat and moisture exchangers does not affect device efficiency or frequency rate of nosocomial pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2000"
                        "volumen" => "28"
                        "paginaInicial" => "1412"
                        "paginaFinal" => "1418"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized clinical trial of extended use of a hydrophobic condenser humidifier&#58; 1 vs&#46; 7 days"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2002"
                        "volumen" => "30"
                        "paginaInicial" => "232"
                        "paginaFinal" => "237"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109705010235"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0335"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2009"
                        "paginaInicial" => "CD000022"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients&#46; Systematic review of randomized&#44; controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2006.10.014"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2007"
                        "volumen" => "65"
                        "paginaInicial" => "187"
                        "paginaFinal" => "203"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care&#58; a randomised controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(03)14409-1"
                      "Revista" => array:7 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2003"
                        "volumen" => "362"
                        "paginaInicial" => "1011"
                        "paginaFinal" => "1016"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673604156900"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Decontamination of the digestive tract and oropharynx in ICU patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0800394"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2009"
                        "volumen" => "360"
                        "paginaInicial" => "20"
                        "paginaFinal" => "31"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units&#58; an open-label&#44; clustered group-randomised&#44; crossover study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(11)70035-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "372"
                        "paginaFinal" => "380"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SOD&#44; or oropharyngeal chlorhexidine to prevent pneumonia and to reduce mortality in ventilated patients&#58; which manoeuvre is evidence-based&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-010-1809-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2010"
                        "volumen" => "36"
                        "paginaInicial" => "1436"
                        "paginaFinal" => "1437"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subglottic secretion drainage for preventing ventilator-associated pneumonia&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjmed.2004.07.051"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "2005"
                        "volumen" => "118"
                        "paginaInicial" => "11"
                        "paginaFinal" => "18"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.08-0103"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2008"
                        "volumen" => "134"
                        "paginaInicial" => "938"
                        "paginaFinal" => "946"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0375"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluation of continuous aspiration of subglottic secretion in an in vivo study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2004"
                        "volumen" => "32"
                        "paginaInicial" => "2071"
                        "paginaFinal" => "2078"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0380"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A new technique of infection prevention in the intensive care unit by selective decontamination of the digestive tract"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Anaesthesiol Belg"
                        "fecha" => "1983"
                        "volumen" => "34"
                        "paginaInicial" => "209"
                        "paginaFinal" => "221"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib0385"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Selective decontamination of the digestive tract&#58; 13 years on&#44; what it is and what it is not"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "1996"
                        "volumen" => "22"
                        "paginaInicial" => "699"
                        "paginaFinal" => "706"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0390"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.155.5.9154884"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1997"
                        "volumen" => "155"
                        "paginaInicial" => "1729"
                        "paginaFinal" => "1734"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0395"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness and cost of selective decontamination of the digestive tract in critically ill intubated patients&#46; A randomized&#44; double-blind&#44; placebo-controlled&#44; multicenter trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.158.3.9712079"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1998"
                        "volumen" => "158"
                        "paginaInicial" => "908"
                        "paginaFinal" => "916"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0400"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.12-1361"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2013"
                        "volumen" => "143"
                        "paginaInicial" => "1219"
                        "paginaFinal" => "1225"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care&#58; an observational&#44; multicentre cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(10)70314-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "181"
                        "paginaFinal" => "189"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack82380"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0245" class="elsevierStylePara elsevierViewall">This manuscript is dedicated to the memory of Dr&#46; Mar&#237;a Jes&#250;s L&#243;pez Pueyo&#46;</p> <p id="par0250" class="elsevierStylePara elsevierViewall">We thank Yolanda Agra &#40;QAA&#41; and the regional healthcare authorities for their commitment&#44; allocation of resources and organizational support of &#8220;Zero VAP&#8221;&#46; The regional and local medical and nurse coordinators deserve mentioning for their outstanding efforts and commitment&#46; Our thanks go also to the intensivists and critical care nurses of the participating units&#44; whose dedication to the implementation of the proposed measures was decisive in actually making &#8220;Zero VAP&#8221; possible&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/21735727/0000003800000004/v1_201405150137/S217357271400023X/v1_201405150137/en/main.assets"
  "Apartado" => null
  "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003800000004/v1_201405150137/S217357271400023X/v1_201405150137/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357271400023X?idApp=WMIE"
]
Share
Current Issue
Journal Information
Back to article

Statistics

Follow this link to access the full text of the article

Special article
Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish “Zero-VAP” bundle
Paquete de medidas para la prevención de la neumonía asociada a la ventilación mecánica y su aplicación en las UVI españolas. El Proyecto «Neumonía Zero»
F. Álvarez Lermaa, M. Sánchez Garcíab,
Corresponding author
miguel.sanchez@salud.madrid.org
miguelsanchez.areachip@wanadoo.es

Corresponding author.
, L. Lorentec, F. Gordod, J.M. Añóne, J. Álvarezf, M. Palomarg, R. Garcíah, S. Ariasi, M. Vázquez-Calatayudj, R. Jamk
a Servicio de Medicina Intensiva, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
b Servicio de Medicina Intensiva, Hospital Clínico San Carlos, Madrid, Spain
c Servicio de Medicina Intensiva, Hospital Universitario de Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
d Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Spain
e Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, Spain
f Servicio de Cuidados Intensivos, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
g Servicio de Medicina Intensiva, Hospital Universitario Arnau de Vilanova, Lérida, Spain
h Servicio de Anestesia y Reanimación, Hospital Universitario de Basurto, Bilbao, Vizcaya, Spain
i Servicio de Medicina Intensiva, Hospital Universitario de Getafe, Getafe, Madrid, Spain
j Servicio de Medicina Intensiva, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
k Servicio de Medicina Intensiva, Centro Hospitalario Parc Taulí, Sabadell, Barcelona, Spain
Ver más
Read
38157
Times
was read the article
8368
Total PDF
29789
Total HTML
Share statistics
 array:23 [
  "pii" => "S217357271400023X"
  "issn" => "21735727"
  "doi" => "10.1016/j.medine.2013.12.001"
  "estado" => "S300"
  "fechaPublicacion" => "2014-05-01"
  "aid" => "662"
  "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and SEMICYUC"
  "copyrightAnyo" => "2013"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "fla"
  "cita" => "Med Intensiva. 2014;38:226-36"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 14971
    "formatos" => array:3 [
      "EPUB" => 235
      "HTML" => 11231
      "PDF" => 3505
    ]
  ]
  "Traduccion" => array:1 [
    "en" => array:19 [
      "pii" => "S0210569114000126"
      "issn" => "02105691"
      "doi" => "10.1016/j.medin.2013.12.007"
      "estado" => "S300"
      "fechaPublicacion" => "2014-05-01"
      "aid" => "662"
      "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and SEMICYUC"
      "documento" => "article"
      "crossmark" => 0
      "subdocumento" => "fla"
      "cita" => "Med Intensiva. 2014;38:226-36"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 9993
        "formatos" => array:3 [
          "EPUB" => 183
          "HTML" => 6789
          "PDF" => 3021
        ]
      ]
      "en" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>"
        "titulo" => "Guidelines for the prevention of ventilator-associated pneumonia and their implementation&#46; The Spanish &#8220;Zero-VAP&#8221; bundle"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => array:2 [
          0 => "en"
          1 => "es"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "226"
            "paginaFinal" => "236"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "es" => array:1 [
            "titulo" => "Paquete de medidas para la prevenci&#243;n de la neumon&#237;a asociada a la ventilaci&#243;n mec&#225;nica y su aplicaci&#243;n en las UVI espa&#241;olas&#46; El Proyecto &#171;Neumon&#237;a Zero&#187;"
          ]
        ]
        "contieneResumen" => array:2 [
          "en" => true
          "es" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "en" => true
        ]
        "contienePdf" => array:1 [
          "en" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figure 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 3500
                "Ancho" => 2691
                "Tamanyo" => 374093
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Organizational scheme of the &#8220;Zero VAP&#8221; Project&#46; &#40;SEMICYUC&#58; Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias&#46; SEEIUC&#58; Sociedad Espa&#241;ola de Enfermer&#237;a Intensiva y Unidades Coronarias&#41;&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "F&#46; &#193;lvarez Lerma, M&#46; S&#225;nchez Garc&#237;a, L&#46; Lorente, F&#46; Gordo, J&#46;M&#46; A&#241;&#243;n, J&#46; &#193;lvarez, M&#46; Palomar, R&#46; Garc&#237;a, S&#46; Arias, M&#46; V&#225;zquez-Calatayud, R&#46; Jam"
            "autores" => array:11 [
              0 => array:2 [
                "nombre" => "F&#46;"
                "apellidos" => "&#193;lvarez Lerma"
              ]
              1 => array:2 [
                "nombre" => "M&#46;"
                "apellidos" => "S&#225;nchez Garc&#237;a"
              ]
              2 => array:2 [
                "nombre" => "L&#46;"
                "apellidos" => "Lorente"
              ]
              3 => array:2 [
                "nombre" => "F&#46;"
                "apellidos" => "Gordo"
              ]
              4 => array:2 [
                "nombre" => "J&#46;M&#46;"
                "apellidos" => "A&#241;&#243;n"
              ]
              5 => array:2 [
                "nombre" => "J&#46;"
                "apellidos" => "&#193;lvarez"
              ]
              6 => array:2 [
                "nombre" => "M&#46;"
                "apellidos" => "Palomar"
              ]
              7 => array:2 [
                "nombre" => "R&#46;"
                "apellidos" => "Garc&#237;a"
              ]
              8 => array:2 [
                "nombre" => "S&#46;"
                "apellidos" => "Arias"
              ]
              9 => array:2 [
                "nombre" => "M&#46;"
                "apellidos" => "V&#225;zquez-Calatayud"
              ]
              10 => array:2 [
                "nombre" => "R&#46;"
                "apellidos" => "Jam"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S217357271400023X"
          "doi" => "10.1016/j.medine.2013.12.001"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357271400023X?idApp=WMIE"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569114000126?idApp=WMIE"
      "url" => "/02105691/0000003800000004/v1_201404270108/S0210569114000126/v1_201404270108/en/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2173572714000216"
    "issn" => "21735727"
    "doi" => "10.1016/j.medine.2014.04.001"
    "estado" => "S300"
    "fechaPublicacion" => "2014-05-01"
    "aid" => "643"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and SEMICYUC"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "sco"
    "cita" => "Med Intensiva. 2014;38:249-60"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 11885
      "formatos" => array:3 [
        "EPUB" => 187
        "HTML" => 8545
        "PDF" => 3153
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Update in Intensive Care Medicine&#58; Mechanical ventilation</span>"
      "titulo" => "New modes of assisted mechanical ventilation"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "249"
          "paginaFinal" => "260"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Nuevos modos de ventilaci&#243;n asistida"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 2374
              "Ancho" => 3249
              "Tamanyo" => 364993
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Principles of patient&#8211;ventilator interaction&#46; Assisted ventilation has the difficult task of harmonizing the operation of two complex systems&#44; i&#46;e&#46;&#44; patient and ventilator&#8211;each with its own control center and ventilatory pump&#46; The respiratory control system &#40;RCS&#41; is complex&#44; and is composed of an automatic system and a voluntary system&#46; The afferents transmit the stimuli from the sensors &#40;central and peripheral chemoreceptors&#44; stretch receptors and muscle receptors&#41; to the control system&#44; regulating the neural respiratory impulse&#46; The automatic control system emits the efferents &#40;motor neurons&#41; that activate and regulate the muscle pump&#46; The voluntary system in turn can modulate the activity of the automatic system or directly activate the muscle pump&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "F&#46; Suarez-Sipmann"
          "autores" => array:2 [
            0 => array:2 [
              "nombre" => "F&#46;"
              "apellidos" => "Suarez-Sipmann"
            ]
            1 => array:1 [
              "colaborador" => "in representation of the Acute Respiratory Failure Working Group of the SEMICYUC"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0210569113002507"
        "doi" => "10.1016/j.medin.2013.10.008"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569113002507?idApp=WMIE"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000216?idApp=WMIE"
    "url" => "/21735727/0000003800000004/v1_201405150137/S2173572714000216/v1_201405150137/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>"
    "titulo" => "Guidelines for the prevention of ventilator-associated pneumonia and their implementation&#46; The Spanish &#8220;Zero-VAP&#8221; bundle"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "226"
        "paginaFinal" => "236"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "F&#46; &#193;lvarez Lerma, M&#46; S&#225;nchez Garc&#237;a, L&#46; Lorente, F&#46; Gordo, J&#46;M&#46; A&#241;&#243;n, J&#46; &#193;lvarez, M&#46; Palomar, R&#46; Garc&#237;a, S&#46; Arias, M&#46; V&#225;zquez-Calatayud, R&#46; Jam"
        "autores" => array:11 [
          0 => array:3 [
            "nombre" => "F&#46;"
            "apellidos" => "&#193;lvarez Lerma"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          1 => array:4 [
            "nombre" => "M&#46;"
            "apellidos" => "S&#225;nchez Garc&#237;a"
            "email" => array:2 [
              0 => "miguel&#46;sanchez&#64;salud&#46;madrid&#46;org"
              1 => "miguelsanchez&#46;areachip&#64;wanadoo&#46;es"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">¿</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "L&#46;"
            "apellidos" => "Lorente"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "F&#46;"
            "apellidos" => "Gordo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "J&#46;M&#46;"
            "apellidos" => "A&#241;&#243;n"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "J&#46;"
            "apellidos" => "&#193;lvarez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "M&#46;"
            "apellidos" => "Palomar"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">g</span>"
                "identificador" => "aff0035"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "R&#46;"
            "apellidos" => "Garc&#237;a"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">h</span>"
                "identificador" => "aff0040"
              ]
            ]
          ]
          8 => array:3 [
            "nombre" => "S&#46;"
            "apellidos" => "Arias"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
          9 => array:3 [
            "nombre" => "M&#46;"
            "apellidos" => "V&#225;zquez-Calatayud"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">j</span>"
                "identificador" => "aff0050"
              ]
            ]
          ]
          10 => array:3 [
            "nombre" => "R&#46;"
            "apellidos" => "Jam"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">k</span>"
                "identificador" => "aff0055"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:11 [
          0 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital del Mar&#44; Parc de Salut Mar&#44; Barcelona&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Cl&#237;nico San Carlos&#44; Madrid&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario de Canarias&#44; San Crist&#243;bal de La Laguna&#44; Santa Cruz de Tenerife&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario del Henares&#44; Coslada&#44; Madrid&#44; Spain"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Virgen de la Luz&#44; Cuenca&#44; Spain"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
          5 => array:3 [
            "entidad" => "Servicio de Cuidados Intensivos&#44; Hospital Universitario de Fuenlabrada&#44; Fuenlabrada&#44; Madrid&#44; Spain"
            "etiqueta" => "f"
            "identificador" => "aff0030"
          ]
          6 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario Arnau de Vilanova&#44; L&#233;rida&#44; Spain"
            "etiqueta" => "g"
            "identificador" => "aff0035"
          ]
          7 => array:3 [
            "entidad" => "Servicio de Anestesia y Reanimaci&#243;n&#44; Hospital Universitario de Basurto&#44; Bilbao&#44; Vizcaya&#44; Spain"
            "etiqueta" => "h"
            "identificador" => "aff0040"
          ]
          8 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario de Getafe&#44; Getafe&#44; Madrid&#44; Spain"
            "etiqueta" => "i"
            "identificador" => "aff0045"
          ]
          9 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Cl&#237;nica Universidad de Navarra&#44; Pamplona&#44; Navarra&#44; Spain"
            "etiqueta" => "j"
            "identificador" => "aff0050"
          ]
          10 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Centro Hospitalario Parc Taul&#237;&#44; Sabadell&#44; Barcelona&#44; Spain"
            "etiqueta" => "k"
            "identificador" => "aff0055"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Paquete de medidas para la prevenci&#243;n de la neumon&#237;a asociada a la ventilaci&#243;n mec&#225;nica y su aplicaci&#243;n en las UVI espa&#241;olas&#46; El Proyecto &#171;Neumon&#237;a Zero&#187;"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 3500
            "Ancho" => 2691
            "Tamanyo" => 373584
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Organizational scheme of the &#8220;Zero VAP&#8221; Project&#46; &#40;SEMICYUC&#58; Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias&#46; SEEIUC&#58; Sociedad Espa&#241;ola de Enfermer&#237;a Intensiva y Unidades Coronarias&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ventilator-associated pneumonia &#40;VAP&#41; is the most frequent ICU-acquired infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> It is associated with significant increases in the length of stay&#44; healthcare costs and both crude and attributed mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> Therefore&#44; potential functional&#44; mechanical and pharmacological prevention measures of VAP have frequently been investigated&#44; classified and recommended in accordance with updated available evidence and feasibility&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;17</span></a> Questionnaires&#44; however&#44; repeatedly report that knowledge&#44; implementation and adherence to guidelines are low among nurses and physicians working in ICUs internationally&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The Spanish annual April to June ICU National Nosocomial Infection Surveillance Study &#40;Estudio Nacional de Vigilancia de Infecci&#243;n Nosocomial&#44; &#8220;ENVIN&#8221;&#41;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;2</span></a> shows stable VAP incidence densities of approximately 15 episodes per 1000 days of mechanical ventilation for the years 2000&#8211;2009 in more than 100 ICUs&#46; These figures compare negatively with other national surveillance programs&#46; The United States National Healthcare Safety Network reports mean VAP incidence rates of 3&#46;7 for 2006&#8211;2008&#44; from as low as 2&#46;1 in pediatric medical-surgical ICUs to 10&#46;7 episodes per 1&#46;000 days in burn units<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Recently&#44; the implementation of &#8220;bundles&#8221; of effective measures&#44; compared to individual interventions&#44; has been proposed to reduce the incidence of catheter-related bloodstream infections<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and VAP&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In Spain&#44; a highly successful bacteraemia prevention bundle&#44; named &#8220;Zero Bacteraemia&#8221;&#44; was started and implemented by the Spanish Society of Intensive Care Medicine &#40;SEMICYUC&#41; in 2008<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> under the auspices and financial support of the World Health Organization and the Quality Assurance Agency of the Spanish Ministry of Health &#40;QAA&#41;&#46; The &#8220;Zero-VAP&#8221; Project uses the organizational structure and methodology created for &#8220;Zero-Bacteraemia&#8221;&#46; In this article we describe the methods applied to identify the recommendations to be included in the &#8220;Zero-VAP&#8221; bundle and to accomplish implementation in Spanish ICUs&#46; We also refer to the systems used to monitor compliance and to register the data generated during the project and describe the associated quality assurance program&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Methods and design</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Structure and organization</span><p id="par0020" class="elsevierStylePara elsevierViewall">SEMICYUC and the Spanish Society of Intensive Care Nurses &#40;SEEIUC&#41; lead and coordinate the technical aspects of &#8220;Zero-VAP&#8221; by means of a working contract&#46; The QAA hierarchically involves the 17 regional healthcare authorities and the hospital directors of the participating ICUs and promotes the Project through co-financing with the regional healthcare authorities&#44; nation-wide coordination&#44; dissemination and follow-up &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; For every Spanish autonomous region&#44; as well as in every ICU&#44; an intensivist and an intensive care nurse coordinate &#8220;Zero-VAP&#8221; at their respective level&#46; The definitions of the European CDC<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a> for VAP and tracheobronchitis have been adopted and are available in the user&#39;s manual of ENVIN-HELICS&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In brief&#44; the presence of these features suggest VAP&#58; two or more serial chest X-rays or CT scans with a suggestive image for patients with underlying cardiac or pulmonary disease&#44; or one definitive chest X-ray or CT scan in patients without underlying cardiac or pulmonary disease&#44; with fever &#62;38<span class="elsevierStyleHsp" style=""></span>&#176;C and&#47;or leucocytosis &#8805;12&#44;000<span class="elsevierStyleHsp" style=""></span>WBC&#47;mm<span class="elsevierStyleSup">3</span> or leucopenia &#8804;4000<span class="elsevierStyleHsp" style=""></span>WBC&#47;mm<span class="elsevierStyleSup">3</span>&#44; and at least one of the following&#58; &#40;1&#41; new onset purulent sputum or change of character of sputum&#59; &#40;2&#41; cough&#44; dyspnea or tachycardia&#59; &#40;3&#41; suggestive auscultation or &#40;4&#41; worsening gas exchange&#46; VAP episodes were additionally stratified according to the microbiological sampling diagnostic method employed&#46; The target of reduction of VAP to less than 9 episodes per 1000 days of mechanical ventilation was chosen because compared to the period 2000&#8211;2009 and the most recent results it represents reductions of 40&#37; and 25&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A national task force with members of SEMICYUC and SEEIUC selected the prevention measures and will be in charge of the management of the Project&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The VAP prevention bundle&#44; the objectives and tools for implementation and control of &#8220;Zero-VAP&#8221; were presented at a national meeting and subsequently at regional and local meetings&#46; The &#8220;Zero-VAP&#8221; guidelines are an extension of ENVIN-HELICS&#44; which collects epidemiological data from all patients admitted to participating ICUs from April 1st to June 30th yearly since 1994 and does not require ethics committee approval&#46; Viewed as a quality improvement initiative&#44; neither the Spanish Ministry of Health nor the regional healthcare authorities requested evaluation of the project by local or regional ethics committees&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Selection of ventilator-associated pneumonia prevention measures</span><p id="par0035" class="elsevierStylePara elsevierViewall">Thirty-five interventions were derived from published clinical trials&#44; guidelines&#44; systematic reviews and meta-analyses&#46; They were classified as &#8220;functional&#8221;&#44; &#8220;mechanical&#8221; or &#8220;pharmacological&#8221; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and evaluated independently by teams of at least two members of the task force using the Grading of Recommendations Assessment&#44; Development and Evaluation Working Group methodology<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> &#40;<a id="intr0005" class="elsevierStyleInterRef" href="http://www.gradeworkinggroup.org/">http&#58;&#47;&#47;www&#46;gradeworkinggroup&#46;org&#47;</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Inclusion of 8 debated interventions was resolved by quantitative assessment by the 11 members of the panel&#44; considering &#40;1&#41; the quality of the evidence &#40;10 points&#41;&#44; &#40;2&#41; its safety &#40;5 points&#41;&#44; and its feasibility in Spanish ICUs &#40;5 points&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Finally&#44; feasibility and cost criteria were applied&#44; as recommended&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> based on which groups of 7 &#8220;basic mandatory&#8221; and 3 &#8220;highly recommended&#8221; measures &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41; were generated&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surveillance and control of compliance</span><p id="par0040" class="elsevierStylePara elsevierViewall">Several systems for the surveillance of adhesion to the Project and compliance of the proposed measures have been established&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Participation in the web-based &#8220;ENVIN-HELICS&#8221; registry</span>&#46; ICUs are committed to enter data required for calculation of incidence density of VAP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Provision of education and training to healthcare workers &#40;HCW&#41;</span>&#46; Two educational modules about VAP prevention and patient safety&#44; with their corresponding examinations&#44; are freely accessible on-line<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and continuously monitored for number and category of ICU-HCW successfully completing the tests&#46; Coordinators in each unit have access to this registry and report to the regional coordinators&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Evaluation of compliance</span>&#46; The web-based 6-monthly compliance registry consists of 3 quality indicators&#44; which were arbitrarily selected because of the ease of monitoring&#58; &#40;1&#41; cuff pressure control prior to oral hygiene&#44; &#40;2&#41; the use of chlorhexidine for oral hygiene&#44; and &#40;3&#41; the number of monthly meetings and activities related to the Project&#46; The previous registry for &#8220;Zero Bacteremia&#8221;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> remains active&#58; &#40;1&#41; a checklist for the insertion of vascular catheters&#44; &#40;2&#41; chlorhexidine skin disinfection&#44; &#40;3&#41; availability of a vascular catheter insertion cart&#44; &#40;4&#41; achievement of daily objectives&#44; &#40;5&#41; meeting with hospital directors and &#40;6&#41; &#8220;learning from errors&#8221; meetings&#46; Information about how many indicators are accomplished is available on-line&#46; The optional &#8220;highly recommended&#8221; measure&#40;s&#41; implemented at each ICU will be captured from the general database &#40;SDD&#41; and from a structured questionnaire &#40;subglottic aspiration and short course of iv antibiotic&#41; to allow for a separate comparative statistical analysis&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Database</span><p id="par0060" class="elsevierStylePara elsevierViewall">&#8220;Zero VAP&#8221; data are recorded through a specific adaptation of the &#8220;ENVIN-HELICS&#8221; web page &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://hws.vhebron.net/Neumonia-zero/">http&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;Neumonia-zero&#47;</a>&#41;&#46; Participating ICUs record data of patients meeting the definition of VAP&#46; In addition&#44; monthly information about risk factors&#44; including total patient-days and ventilated patient-days&#44; is provided&#46; If a patient develops VAP&#44; a database entry is created with information on demographics&#44; risk factors&#44; severity at ICU admission&#44; underlying conditions&#44; comorbidity&#44; diagnostic criteria&#44; microbiological sampling procedures&#44; etiology and clinical course&#46; Patients entered in the &#8220;ENVIN-HELICS&#8221; surveillance program are recorded automatically in the &#8220;Zero VAP&#8221; database&#44; with no additional intervention being required&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Summary descriptive statistics are available on-line for every individual unit&#44; which may directly access its data on a daily basis&#46; Local results are displayed together with the corresponding regional and national values&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Detailed educational slide presentations for every component of both &#8220;basic mandatory&#8221; and &#8220;highly recommend&#8221; measures can be freely accessed at <a id="intr0015" class="elsevierStyleInterRef" href="http://hws.vhebron.net/Neumonia-zero/">http&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;Neumonia-zero&#47;</a>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Basic mandatory measures</span><p id="par0075" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Education and training in airway management</span> &#40;aspiration of bronchial secretions&#41;&#46; A systematic review including 26 studies<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> suggests that educational interventions are associated with significant reductions in nosocomial infection rates&#44; although a causal relation cannot be established due to limitations in study design&#46; Several studies show significant reductions in VAP incidence after implementation of educational programs<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a> and simple clinical protocols&#44; including emphasis on strict hand hygiene&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Although the quality of evidence for educational interventions for airway management is &#8220;moderate&#8221;&#44; the strength of this recommendation was classified as &#8220;strong&#8221; because of its significant association with the prevention of VAP&#44; no major threats for safety&#44; and low cost of implementation&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The specific care practices taught in the educational program to be implemented at the beginning of the project are freely available at <a id="intr0020" class="elsevierStyleInterRef" href="http://hws.vhebron.net/Neumonia-zero/">http&#58;&#47;&#47;hws&#46;vhebron&#46;net&#47;Neumonia-zero&#47;</a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Strict hand hygiene with alcohol solutions before airway management</span>&#46; Observational studies<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> report reductions in nosocomial infection rates and methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MRSA&#41; infection after promoting hand-washing&#46; Hand-washing before and after patient contact and the use of gloves were introduced in 2004 as proven measures for the prevention of VAP and other nosocomial infections&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It is now firmly established as a fundamental component of standard clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The use of gloves does not preclude the obligation of hand-washing with alcohol solutions before and after management of the artificial airway&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Oral hygiene with chlorhexidine</span>&#46; Chlorhexidine has been recommended for MRSA skin decolonization<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#8211;38</span></a> and VAP prevention&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10&#44;15</span></a> Four of 6 meta-analyses<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#8211;44</span></a> show significant reductions of VAP incidence rates with oropharyngeal chlorhexidine&#46; A recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> favors chlorhexidine &#40;OR 0&#46;56&#44; 95&#37;CI 0&#46;44&#8211;0&#46;73&#41;&#44; although 6 of the 10 trials were negative&#46; The variable effect of chlorhexidine seems to be related to its limited microbiological effect&#44; which&#44; while reducing oropharyngeal carriage with <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; leaves Gram-negative colonization largely unaffected&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Efficacy may also be related to the local concentrations of chlorhexidine&#46; A trial administering a high concentration 2&#37; solution showed a significant reduction of VAP&#44; although 10&#37; of patients in the test group developed irritation of the oral mucosa&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Chlorhexidine apparently has no risk of inducing cross-resistance to antibiotics&#46; However&#44; chlorhexidine-resistant strains of MRSA may substitute susceptible strains shortly after initiating routine chlorhexidine application&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a> Up to 63&#37; of European strains actually express plasmid-borne <span class="elsevierStyleItalic">qacA</span>&#47;<span class="elsevierStyleItalic">B</span> genes coding for multidrug efflux pumps&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> which confer chlorhexidine resistance in MRSA&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Oral hygiene with aqueous chlorhexidine solutions &#40;0&#46;12&#8211;2&#37;&#41; should be performed every 8<span class="elsevierStyleHsp" style=""></span>h&#46; Before its application&#44; cuff pressure should be above 20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; Formal training of nurse&#39;s aides&#44; responsible for this procedure in most ICUs&#44; will be done&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Control and maintenance of cuff pressure</span>&#46; Although included in the guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> this recommendation is based on the results of a small single-centre&#44; non-comparative study<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> suggesting that a cuff pressure level below 20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O is associated with an increased risk of VAP in patients not receiving systemic antibiotics&#46; A recent randomized trial&#44; comparing continuous monitoring of cuff pressure with intermittent or non-scheduled measurements&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> did not confirm this association in spite of a significant difference in the incidence of cuff pressures below 20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; The panel considered that routine checks of cuff pressure is a simple low cost standard clinical procedure&#44; also controlling for inappropriately high pressures and should be scheduled at 8<span class="elsevierStyleHsp" style=""></span>h intervals and set at 20&#8211;30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O before oral application of chlorhexidine&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">5&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Semi-recumbent positioning&#46; Avoidance of 0&#176; supine positioning</span>&#46; The physiologic rationale behind semi-recumbent positioning is that it may favor spontaneous ventilation and reduce aspiration of contaminated gastric content&#46; Its effect on VAP prevention has not been validated in unstable patients or patients with increased intra-abdominal pressure&#44; and results of randomized trials vary&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#44;53</span></a> A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> using a random effects model to compensate for significant heterogeneity observed a non-significant reduction in the incidence of VAP &#40;OR 0&#46;59&#44; 95&#37;CI 0&#46;15&#8211;2&#46;35&#41; in patients in a semi-recumbent 45&#176; position&#46; A recent well-conducted randomized trial<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> enrolling 232 patients with tetanus was negative&#44; with 20&#46;8&#37; &#40;39&#46;2 episodes per 1000 days of ventilation&#41; patients developing VAP in supine position and 25&#37; &#40;38&#46;1 episodes&#41; in semi-recumbence &#40;OR 0&#46;79&#44; 95&#37;CI 0&#46;39&#8211;1&#46;57&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;46&#41;&#46; Differing study results prevent establishing a firm recommendation to elevate backrests to 45&#176;&#46; However&#44; it is recommended to avoid 0&#176; supine positioning in patients receiving enteral feeding and with no contraindication&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">6&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Promoting procedures and protocols that safely avoid or reduce duration of mechanical ventilation</span>&#46; Effective interventions aimed at avoiding or shortening duration of endotracheal intubation are associated with reductions of VAP&#46; Therefore&#44; protocols for non-invasive mechanical ventilation &#40;NIMV&#41; in acute exacerbations of chronic obstructive pulmonary disease &#40;COPD&#41;&#44; for weaning or for sedation promoting lower infusion doses or its daily interruption should be available&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">NIMV appears to be associated with reduced mortality and VAP &#40;relative risk 0&#46;29&#44; 95&#37;CI 0&#46;19&#8211;0&#46;45&#41; when used as a weaning strategy in patients with COPD after extubation&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">A recent systematic review<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> suggests that the use of weaning protocols is associated with a reduced duration of mechanical ventilation&#46; However&#44; significant heterogeneity between studies and the absence of data on VAP preclude grading of evidence of this potentially preventive measure&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">To our knowledge&#44; no study evaluating the effect of daily sedation vacation on VAP incidence as end-point has been performed&#46; Two landmark trials evaluating daily interruption of sedation did not mention comparative VAP rates&#44; although both found significant reductions in the duration of mechanical ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">58&#44;59</span></a> Therefore&#44; the quality of the evidence of VAP prevention by reducing sedation could not be appropriately graded&#46; A detailed sedation protocol was deemed to be beyond the scope of the Project&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Based on the available data&#44; the panel decided to issue a generic recommendation for the availability of updated weaning and sedation protocols and for the use of NIMV in selected patient populations&#44; to reduce the duration of mechanical ventilation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">7&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Avoidance of elective changes of ventilator circuits&#44; humidifiers and endotracheal tubes</span>&#46; Planned ventilator circuit changes may increase cost and the risk of VAP and should not be performed&#44; as has already been recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11</span></a> A systematic review<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> confirms that 48<span class="elsevierStyleHsp" style=""></span>h circuit changes compared to 7 days almost double the risk of VAP &#40;OR 1&#46;93&#44; 95&#37;CI 1&#46;08&#8211;3&#46;44&#41;&#46; It is concluded that the practice of planned ventilator circuit changes should be abandoned&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Heat-moisture exchangers &#40;HME&#41; have been suggested to be associated with lower incidence of VAP than heated humidifiers &#40;HH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> A recent meta-analysis does not confirm this effect<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> and&#44; therefore&#44; HH should be reserved for individual cases at increased risk of airway obstruction&#46; The adequate frequency of change of HME has not been established&#46; The results of prospective before-after studies and randomized trials indicate that prolonging the duration of HMEs from 24 to 48<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63&#44;64</span></a> to 5 days&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> and even to 7 days&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> reduces costs and does not increase VAP&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Highly recommended measures</span><p id="par0150" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Selective Decontamination of the Digestive Tract &#40;SDD&#41; or Selective Oropharyngeal Decontamination &#40;SOD&#41;</span>&#46; This intervention aims at the reduction of endogenous infections by preventing or eradicating the aero-digestive carrier state with potentially pathogenic flora&#46; The SDD protocol includes administration of a short 2- to 5-day course of a third generation cephalosporin and topical antibiotics administered as a paste to the oral mucosa and as a solution via nasogastric tube&#46; The topical antimicrobials are non-absorbable to maintain high luminal gut concentrations and prevent the development of resistance&#46; This strategy has no effect on exogenous infections&#44; which are caused by direct inoculation&#44; although it may reduce cross-transmission&#46; SDD is associated with reductions of VAP of approximately 70&#37; in 60 randomized trials and 15 meta-analyses&#46; A recent individual patient meta-analysis<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> calculated an odds ratio of 0&#46;28 &#40;95&#37;CI 0&#46;20&#8211;0&#46;38&#41; for the development of VAP&#46; SDD is also associated with significant reductions in bacteraemia &#40;OR 0&#46;73&#44; 95&#37;CI 0&#46;59&#8211;0&#46;9&#41;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> and mortality &#40;OR 0&#46;75&#44; 95&#37;CI 0&#46;65&#8211;0&#46;87&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> Although concerns about the development of resistance during SDD have been voiced&#44; the most recent and biggest randomized multicentre trials demonstrate significant reductions of incidence rates of multi-drug resistant bacteria &#40;MDR&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#8211;71</span></a> SOD&#44; studied in 9 controlled trials&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> drastically reduces VAP risk &#40;OR 0&#46;17&#44; 95&#37;CI 0&#46;17&#8211;0&#46;43&#41;&#44; although not mortality&#44; or gastro-intestinal carriage with MDR&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#44;71</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The implementation of SDD and SOD requires the collaboration of several hospital departments&#44; such as critical care&#44; microbiology and pharmacy and neither the antimicrobial paste nor the oral solution is commercially available&#46; Therefore&#44; although the panel considered the quality of the evidence favoring SDD to be &#8220;high&#8221; and strongly recommends its use&#44; it was not categorized as a basic mandatory measure&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In order to facilitate its implementation&#44; the instructions for manufacture&#44; administration and surveillance are provided&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">2&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Continuous aspiration of subglottic secretions &#40;CASS&#41;</span>&#46; A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> found that CASS significantly reduces early-onset VAP &#40;EO-VAP&#41; in patients exceeding 3 days of intubation &#40;risk ratio for all episodes 0&#46;51&#44; 95&#37;CI 0&#46;37&#8211;0&#46;71&#44; for EO-VAP 0&#46;38&#44; 95&#37;CI 0&#46;16&#8211;0&#46;88&#41;&#44; although it does not prevent colonization or infection of the respiratory tract with <span class="elsevierStyleItalic">Enterobacteriaceae</span> or <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#46; The duration of mechanical ventilation and that of ICU stay were reduced by 2 days &#40;95&#37;CI 1&#46;7&#8211;2&#46;3&#41; and 3 days &#40;95&#37;CI 2&#46;1&#8211;3&#46;9&#41;&#44; respectively&#44; with no effect on mortality&#46; A recent randomized trial in patients undergoing a major heart surgery<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> was negative&#46; A post hoc sub-group analysis of patients ventilated more than 48<span class="elsevierStyleHsp" style=""></span>h found significant reductions of cumulative incidence of VAP &#40;26&#46;7&#37; vs&#46; 47&#46;5&#37;&#44; relative risk 0&#46;40&#44; 95&#37;CI 0&#46;16&#8211;0&#46;99&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#44; ICU length-of-stay &#40;7 vs&#46; 16&#46;5 days&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and antibiotic use&#44; with no effect on mortality&#46; No adverse events attributed to CASS have been reported in humans&#44; although evidence of widespread injury to tracheal mucosa and submucosa was documented after 72<span class="elsevierStyleHsp" style=""></span>h of CASS in sheep&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">As for SDD&#44; CASS is not widely available and expensive&#46; Instructions for its use are provided&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">3&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Short course &#40;2&#8211;3 days&#41; of systemic antibiotic therapy</span>&#46; A short course of intravenous cephalosporin was added to topical antibiotics in the SDD protocol in order to prevent primary endogenous&#44; mainly respiratory tract&#44; infection in severe trauma patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">76&#44;77</span></a> This measure has been evaluated separately for the prevention of VAP&#44; without concomitant administration of topical antimicrobials&#44; and was therefore included in the bundle for those ICUs not implementing the complete SDD protocol&#46;</p></li></ul></p><p id="par0185" class="elsevierStylePara elsevierViewall">Patients with decreased level of consciousness are particularly at a high risk of primary endogenous VAP&#44; typically including severe trauma&#44; severe head trauma&#44; stroke&#44; cardiac arrest and metabolic or drug-related central nervous system depression&#46; A small randomized controlled trial<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> showed a significant reduction of the incidence of VAP from 36&#37; to 18&#37; associated with the administration of only 2 doses of cefuroxime 1&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;12<span class="elsevierStyleHsp" style=""></span>h&#46; In a double-blind randomized multicentre trial&#44; 3 doses of ceftriaxone 2<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h were associated with a significant reduction of primary endogenous VAP from 51&#46;3&#37; to 14&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> Intravenous antibiotics have shown to be protective<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#44;80</span></a> and are therefore recommended&#44; similar to surgical prophylaxis&#44; in the aforementioned patient populations&#44; although they do not reduce late infections&#44; morbidity or mortality&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In patients with decreased level of consciousness&#44; a short 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h course of intravenous cefuroxime&#44; ceftriaxone or amoxicillin-clavulanate should be considered&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0195" class="elsevierStylePara elsevierViewall">The last decade has witnessed the publication of rigorous and comprehensive guidelines for the prevention of VAP&#44; generated with ever-improving and transparent methodologies&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10&#44;49&#44;9&#44;11&#8211;15</span></a> which have provided detailed reviews of the literature and thoughtful recommendations&#46; The Spanish &#8220;Zero VAP&#8221; Project&#44; developed under the leadership of SEMICYUC&#44; has several additional differential features&#44; which in our opinion extends the value of this initiative beyond that of its 7 &#8220;basic&#8221; and 3 &#8220;highly recommended&#8221; or other published &#8220;conventional&#8221; guidelines&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Beyond the usual physician-led recommendations&#44; this project was developed from its earliest phases in collaboration with the Spanish critical care nurses &#40;SEEIUC&#41;&#44; who participated actively in all theoretical and practical aspects of its design&#44; training&#44; implementation&#44; adherence&#44; compliance&#44; quality assurance and coordination&#46; The active role of the nurses and their identification with the initiative were considered to be an essential element for success&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">&#8220;Zero-VAP&#8221; is an interventional program incorporated into a firmly established observational ICU infection surveillance program&#44; ENVIN-HELICS&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which the Working Group for Infectious Diseases of SEMICYUC initiated in 1994&#46; ENVIN-HELICS yearly collects data from ICU patients staying<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>h and who are admitted during the surveillance period&#44; which spans from April 1st to June 30th&#46; The ever increasing number of participating ICUs reached 173 in 2012&#46; The huge amount of epidemiological data and surveillance experience accumulated over 18 years in 150&#44;000 patients by Spanish intensivists and critical care nurses constitute a solid historical control group providing the adequate baseline reference data&#46; &#8220;Zero-VAP&#8221; may therefore be viewed as a huge&#44; multicentre&#44; &#8220;before-after&#8221; study&#44; where the efficacy of a VAP prevention bundle is prospectively evaluated&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The establishment of an organizational structure and contractual commitment involving the Spanish Ministry of Health&#44; regional authorities&#44; hospital directors&#44; and regional and site medical and nurse coordinators is another differential characteristic of &#8220;Zero-VAP&#8221;&#44; with the objective to guarantee continued adherence and quality&#46; In addition&#44; continuous monitoring of compliance will also allow validating the prevention package and some of its individual measures&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Compared to conventional guidelines&#44; &#8220;Zero-VAP&#8221; is a bundle of interventions with a pre-defined objective&#46; The reduction of the national VAP incidence rate by 25&#37; and to less than 9 episodes per 1000 days of mechanical ventilation is a simple and clear quantitative target&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Finally&#44; the validation for efficacy and safety of expert recommendations in &#8220;real life&#8221; situations&#44; even if these are produced by the best of methodologies&#44; seems to be becoming more and more important&#46; It may even be argued that future guidelines should be accompanied by evaluation for adequacy and safety&#44; i&#46;e&#46; internal validity&#44; before widespread implementation of recommendations&#46; Performance of randomized trials before implementation of guidelines has recently been proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> In addition&#44; the results of implementing recommendations&#44; i&#46;e&#46; external validity&#44; should ideally be assessable on a continuous basis&#44; similar to phase IV or post-marketing studies of new antimicrobial compounds&#44; thus allowing for early detection of adverse outcomes&#46; &#8220;Zero-VAP&#8221;&#44; through its continuous on-line recording of results and incorporated patient safety and quality improvement program&#44; has efficient incorporated tools to detect and correct errors and to implement modifications or improvements&#44; thereby also guaranteeing future adherence to recommendations&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The weaknesses of &#8220;Zero-VAP&#8221; are related to the &#8220;study&#8221; design and to the absence of site monitoring&#46; Compared to an ideal multicentre&#44; randomized&#44; control trial&#44; the current project has only a historic control group&#44; and confounding variables cannot be definitively excluded&#46; Also&#44; although pre-defined diagnostic criteria exist&#44; underreporting of VAP episodes may start to occur if during the project&#44; candidate VAP episodes are evaluated with stricter criteria than in previous practice&#46; Although a desirable &#8220;fringe benefit&#8221; of the project&#44; this effect may falsely improve the results of implementation of the VAP prevention bundle&#46; Unfortunately&#44; the financial support of the project does not cover site monitoring to detect VAP episodes that are not reported but treated as such with antimicrobials&#46; Monitoring of more than 200 ICUs would require allocation of important economic resources&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In summary&#44; we present &#8220;Zero-VAP&#8221;&#44; the Spanish national VAP prevention bundle&#44; with its organizational structure involving several levels of the healthcare administration&#44; and provide a detailed description of the methodology used for selecting the components of the bundle&#46; Online tools put in place facilitate implementation and adherence and measure compliance and the effect of the bundle on the incidence of VAP in Spanish ICUs&#46; &#8220;Zero-VAP&#8221; also promotes the development of a culture of safety assurance in ICUs&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0235" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleGrantSponsor" id="gs0005">Spanish Ministry of Health</span> provided financial support for the meetings of the task force&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have no competing interests&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:2 [
          "identificador" => "xres339236"
          "titulo" => array:4 [
            0 => "Abstract"
            1 => "Background"
            2 => "Methods&#47;design"
            3 => "Discussion"
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec320810"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres339237"
          "titulo" => array:4 [
            0 => "Resumen"
            1 => "Antecedentes"
            2 => "M&#233;todos&#47;dise&#241;o"
            3 => "Debate"
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec320811"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Background"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Methods and design"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Structure and organization"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Selection of ventilator-associated pneumonia prevention measures"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Surveillance and control of compliance"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Database"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Basic mandatory measures"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Highly recommended measures"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Funding"
        ]
        8 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflicts of interest"
        ]
        9 => array:2 [
          "identificador" => "xack82380"
          "titulo" => "Acknowledgements"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-11-11"
    "fechaAceptado" => "2013-12-16"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec320810"
          "palabras" => array:6 [
            0 => "Ventilator-associated pneumonia"
            1 => "Intensive care unit"
            2 => "Mechanical ventilation"
            3 => "Prevention bundle"
            4 => "Guidelines"
            5 => "Safety assurance"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec320811"
          "palabras" => array:6 [
            0 => "Neumon&#237;a asociada a la ventilaci&#243;n mec&#225;nica"
            1 => "Unidad de cuidados intensivos"
            2 => "Ventilaci&#243;n mec&#225;nica"
            3 => "Haz de prevenci&#243;n"
            4 => "Directrices"
            5 => "Control de la seguridad"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#8220;Zero-VAP&#8221; is a proposal for the implementation of a simultaneous multimodal intervention in Spanish intensive care units &#40;ICU&#41; consisting of a bundle of ventilator-associated pneumonia &#40;VAP&#41; prevention measures&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods&#47;design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An initiative of the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses&#44; the project is supported by the Spanish Ministry of Health&#44; and participation is voluntary&#46; In addition to guidelines for VAP prevention&#44; the &#8220;Zero-VAP&#8221; Project incorporates an integral patient safety program and continuous online validation of the application of the bundle&#46; For the latter&#44; VAP episodes and participation indices are entered into the web-based Spanish ICU Infection Surveillance Program &#8220;ENVIN-HELICS&#8221; database&#44; which provides continuous information about local&#44; regional and national VAP incidence rates&#46; Implementation of the guidelines aims at the reduction of VAP to less than 9 episodes per 1000 days of mechanical ventilation&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 35 preventive measures were initially selected&#46; A task force of experts used the Grading of Recommendations&#44; Assessment&#44; Development and Evaluation Working Group methodology to generate a list of 7 basic &#8220;mandatory&#8221; recommendations &#40;education and training in airway management&#44; strict hand hygiene for airway management&#44; cuff pressure control&#44; oral hygiene with chlorhexidine&#44; semi-recumbent positioning&#44; promoting measures that safely avoid or reduce time on ventilator&#44; and discouraging scheduled changes of ventilator circuits&#44; humidifiers and endotracheal tubes&#41; and 3 additional &#8220;highly recommended&#8221; measures &#40;selective decontamination of the digestive tract&#44; aspiration of subglottic secretions&#44; and a short course of iv antibiotic&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We present the Spanish VAP prevention guidelines and describe the methodology used for the selection and implementation of the recommendations and the organizational structure of the project&#46; Compared to conventional guideline documents&#44; the associated safety assurance program&#44; the online data recording and compliance control systems&#44; as well as the existence of a pre-defined objective are the distinct features of &#8220;Zero VAP&#8221;&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0030">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#171;Neumon&#237;a Zero&#187; es una propuesta de aplicaci&#243;n de una intervenci&#243;n multimodal simult&#225;nea en las unidades de cuidados intensivos espa&#241;olas que consiste en un paquete de medidas preventivas de la neumon&#237;a asociada a la ventilaci&#243;n mec&#225;nica &#40;NAVM&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0035">M&#233;todos&#47;dise&#241;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se trata de una iniciativa de las sociedades espa&#241;olas de Medicina Intensiva y Enfermer&#237;a Intensiva&#46; El proyecto cuenta con el apoyo del Ministerio de Sanidad y la participaci&#243;n es voluntaria&#46; Adem&#225;s de las directrices para la prevenci&#243;n de la NAVM&#44; el proyecto &#171;Neumon&#237;a Zero&#187; incluye un programa integral de seguridad del paciente y una validaci&#243;n continua &#171;online&#187; de la aplicaci&#243;n de las medidas&#46; Para ello se introducen los episodios de NAVM y los &#237;ndices de participaci&#243;n en la base de datos en red del programa &#171;ENVIN-HELICS&#187; de vigilancia de las infecciones en las unidades de cuidados intensivos espa&#241;olas&#44; que ofrece informaci&#243;n continua acerca de las tasas de incidencia de NAVM a nivel local&#44; auton&#243;mico y nacional&#46; La aplicaci&#243;n de &#171;Neumon&#237;a Zero&#187; pretende reducir las NAVM a menos de 9 episodios por cada 1&#46;000 d&#237;as de ventilaci&#243;n mec&#225;nica&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Inicialmente&#44; se seleccionaron 35 medidas de prevenci&#243;n&#46; Un grupo de expertos utiliz&#243; la metodolog&#237;a del Grading of Recommendations&#44; Assessment&#44; Development and Evaluation Working Group para crear una lista de 7 recomendaciones b&#225;sicas &#171;obligatorias&#187; &#40;formaci&#243;n y entrenamiento en el manejo de la v&#237;a a&#233;rea&#44; higiene estricta de manos en el manejo de la v&#237;a a&#233;rea&#44; control de la presi&#243;n del neumotaponamiento&#44; higiene bucal con clorhexidina&#44; posici&#243;n semiincorporada&#44; fomento de medidas que de forma segura eviten o reduzcan la duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; y desaconsejar los cambios programados de tubuladuras&#44; humidificadores y tubos endotraqueales&#41; y 3 medidas adicionales &#171;muy recomendables&#187; &#40;descontaminaci&#243;n selectiva del tubo digestivo&#44; aspiraci&#243;n de las secreciones subgl&#243;ticas y un breve curso de antibi&#243;ticos intravenosos&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Debate</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Presentamos las directrices espa&#241;olas para la prevenci&#243;n de la NAVM y describimos la metodolog&#237;a utilizada para seleccionar y aplicar las recomendaciones y la estructura organizativa del proyecto&#46; En comparaci&#243;n con recomendaciones convencionales&#44; el programa de seguridad asociado&#44; el registro de datos &#171;online&#187; y los sistemas de control del cumplimiento&#44; adem&#225;s de la existencia de un objetivo predefinido&#44; son caracter&#237;sticas distintivas de &#171;Neumon&#237;a Zero&#187;&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 3500
            "Ancho" => 2691
            "Tamanyo" => 373584
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Organizational scheme of the &#8220;Zero VAP&#8221; Project&#46; &#40;SEMICYUC&#58; Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias&#46; SEEIUC&#58; Sociedad Espa&#241;ola de Enfermer&#237;a Intensiva y Unidades Coronarias&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Functional</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Semi-recumbent position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Strict hand hygiene with alcohol-based gels or solutions before airway management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Education and training in aspiration of bronchial secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Daily sedation vacation and assessment of weaning and extubation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Availability of weaning protocols&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; Early tracheostomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; Non-invasive mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>8&#46; Microbiological surveillance of cross-contamination and infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>9&#46; Instillation of normal saline prior to endotracheal suctioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>10&#46; Ventilator tubing change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>11&#46; Route of endotracheal intubation&#46; Orotracheal vs&#46; nasotracheal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>12&#46; Type of airway humidification&#46; Preference of heat moisture exchanger or heated humidifier&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>13&#46; Physiotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>14&#46; Positive end-expiratory airway pressure &#40;PEEP&#41; of 5&#8211;8<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O vs&#46; Zero end-expiratory pressure &#40;ZEEP&#41; in patients without lung injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>15&#46; Enteral feeding&#58; route of administration and gastric residual volumes&#46; Use of prokinetics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Mechanical</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Endotracheal tube cuff pressure monitoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Subglottic secretion drainage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Polyurethane-cuffed endotracheal tubes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Polyurethane-cuffed endotracheal tubes with subglottic secretion drainage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Silver-coated endotracheal tubes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; High-volume&#44; low-pressure endotracheal tube cuff&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; Small caliber feeding tubes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>8&#46; Aspiration of tracheobronchial secretions with closed vs&#46; open systems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>9&#46; Endotracheal tube biofilm removal device &#40;Mucus Shaver<span class="elsevierStyleSup">&#174;</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>10&#46; Kinetic bed therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>11&#46; Airway filters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>12&#46; Water-soluble gel lubrication of the endotracheal tube&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>13&#46; Tooth brushing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pharmacological</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Selective decontamination of the digestive tract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Selective oropharyngeal decontamination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Short course of intravenous antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Oral hygiene with chlorhexidine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Nebulized antibiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; Antibiotic cycling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; Probiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab500919.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Classification of VAP prevention methods&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Quality of evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">High</span>&#46; Further research is very unlikely to change our confidence in the estimate of effect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Moderate</span>&#46; Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Low</span>&#46; Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Very low</span>&#46; Any estimate of effect is very uncertain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Degree of recommendation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Strong</span>&#46; Indicating a judgment that most well informed people would make&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Weak</span>&#46; Indicating a judgment that a majority of well-informed people would make but a substantial minority would not&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab500921.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Definitions of quality of evidence and category of recommendation according to the Grading of Recommendations Assessment&#44; Development and Evaluation Working Group&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;2</span></a><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Efficacy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Adverse events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Feasibility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aspiration of subglottic secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid filter and tubing changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">171&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Semi-recumbent positioning&#46; Avoid 0&#176;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Monitoring and control of cuff pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral hygiene with chlorhexidine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">163&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SDD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SOD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Short course of intravenous antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab500922.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Mean individual score of measures categorized as &#8220;strong&#8221; recommendation&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Quality of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Basic mandatory</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Education and training in appropriate airway management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Strict hand hygiene for airway management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Cuff pressure control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Oral hygiene with chlorhexidine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Semi-recumbent positioning&#46; Avoid 0&#176;&#44; if possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; Promote procedures and protocols which safely avoid or reduce time on ventilator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; Avoid scheduled change of ventilator circuit&#44; humidifiers and endotracheal tubes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Highly recommended measures</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Selective Decontamination of the Digestive Tract or Selective Decontamination of the Oropharynx&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Aspiration of subglottic secretions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Short course of intravenous antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab500920.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Quality of evidence of individual components of the VAP prevention bundle&#46; All interventions were categorized as &#8220;highly recommended&#8221;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:81 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "National Healthcare Safety Network &#40;NHSN&#41; report&#58; data summary for 2006 through 2008&#44; issued December 2009"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;R&#46; Edwards"
                            1 => "K&#46;D&#46; Peterson"
                            2 => "Y&#46; Mu"
                            3 => "S&#46; Banerjee"
                            4 => "K&#46; Allen-Bridson"
                            5 => "G&#46; Morrell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ajic.2009.10.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Infect Control"
                        "fecha" => "2009"
                        "volumen" => "37"
                        "paginaInicial" => "783"
                        "paginaFinal" => "805"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20004811"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology and impact of nosocomial infections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46;M&#46; Olaechea"
                            1 => "J&#46; Insausti"
                            2 => "A&#46; Blanco"
                            3 => "P&#46; Luque"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2009.11.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2010"
                        "volumen" => "34"
                        "paginaInicial" => "256"
                        "paginaFinal" => "267"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20096484"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Estudio Nacional de Vigilancia de Infecci&#243;n Nosocomial en UCI &#40;ENVIN-UCI&#41; 2001&#8211;2009"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2012"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nosocomial infection&#44; length of stay&#44; and time-dependent bias"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Beyersmann"
                            1 => "T&#46; Kneib"
                            2 => "M&#46; Schumacher"
                            3 => "P&#46; Gastmeier"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/596020"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2009"
                        "volumen" => "30"
                        "paginaInicial" => "273"
                        "paginaFinal" => "276"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19193018"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46; Chastre"
                            1 => "J&#46;Y&#46; Fagon"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.165.7.2105078"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2002"
                        "volumen" => "165"
                        "paginaInicial" => "867"
                        "paginaFinal" => "903"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11934711"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortality&#44; attributable mortality&#44; and clinical events as end points for clinical trials of ventilator-associated pneumonia and hospital-acquired pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;G&#46; Muscedere"
                            1 => "A&#46; Day"
                            2 => "D&#46;K&#46; Heyland"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/653060"
                      "Revista" => array:7 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2010"
                        "volumen" => "51"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "S120"
                        "paginaFinal" => "S125"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20597661"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical outcomes of health-care-associated infections and antimicrobial resistance in patients admitted to European intensive-care units&#58; a cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;L&#46; Lambert"
                            1 => "C&#46; Suetens"
                            2 => "A&#46; Savey"
                            3 => "M&#46; Palomar"
                            4 => "M&#46; Hiesmayr"
                            5 => "I&#46; Morales"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(10)70258-9"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "30"
                        "paginaFinal" => "38"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21126917"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia&#46; European Task Force on ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Torres"
                            1 => "J&#46; Carlet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2001"
                        "volumen" => "17"
                        "paginaInicial" => "1034"
                        "paginaFinal" => "1045"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11488306"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for preventing health-care-associated pneumonia&#44; 2003&#58; recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "O&#46;C&#46; Tablan"
                            1 => "L&#46;J&#46; Anderson"
                            2 => "R&#46; Besser"
                            3 => "C&#46; Bridges"
                            4 => "R&#46; Hajjeh"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "MMWR Recomm Rep"
                        "fecha" => "2004"
                        "volumen" => "53"
                        "numero" => "RR-3"
                        "paginaInicial" => "1"
                        "paginaFinal" => "36"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15841069"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Dodek"
                            1 => "S&#46; Keenan"
                            2 => "D&#46; Cook"
                            3 => "D&#46; Heyland"
                            4 => "M&#46; Jacka"
                            5 => "L&#46; Hand"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2004"
                        "volumen" => "141"
                        "paginaInicial" => "305"
                        "paginaFinal" => "313"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15313747"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the management of hospital-acquired pneumonia in the UK&#58; report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46;G&#46; Masterton"
                            1 => "A&#46; Galloway"
                            2 => "G&#46; French"
                            3 => "M&#46; Street"
                            4 => "J&#46; Armstrong"
                            5 => "E&#46; Brown"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/jac/dkn162"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Antimicrob Chemother"
                        "fecha" => "2008"
                        "volumen" => "62"
                        "paginaInicial" => "5"
                        "paginaFinal" => "34"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18445577"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia&#58; prevention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Muscedere"
                            1 => "P&#46; Dodek"
                            2 => "S&#46; Keenan"
                            3 => "R&#46; Fowler"
                            4 => "D&#46; Cook"
                            5 => "D&#46; Heyland"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2007.11.014"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2008"
                        "volumen" => "23"
                        "paginaInicial" => "126"
                        "paginaFinal" => "137"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18359430"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Strategies to prevent ventilator-associated pneumonia in acute care hospitals"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;E&#46; Coffin"
                            1 => "M&#46; Klompas"
                            2 => "D&#46; Classen"
                            3 => "K&#46;M&#46; Arias"
                            4 => "K&#46; Podgorny"
                            5 => "D&#46;J&#46; Anderson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/591062"
                      "Revista" => array:7 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2008"
                        "volumen" => "29"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "S31"
                        "paginaFinal" => "S40"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18840087"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Defining&#44; treating and preventing hospital acquired pneumonia&#58; European perspective"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Torres"
                            1 => "S&#46; Ewig"
                            2 => "H&#46; Lode"
                            3 => "J&#46; Carlet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-008-1336-9"
                      "Revista" => array:7 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2009"
                        "volumen" => "35"
                        "paginaInicial" => "9"
                        "paginaFinal" => "29"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18989656"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109701015546"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A European care bundle for prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Rello"
                            1 => "H&#46; Lode"
                            2 => "G&#46; Cornaglia"
                            3 => "R&#46; Masterton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-010-1841-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2010"
                        "volumen" => "36"
                        "paginaInicial" => "773"
                        "paginaFinal" => "780"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20237759"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New issues and controversies in the prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Lorente"
                            1 => "S&#46; Blot"
                            2 => "J&#46; Rello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.201001-0081CI"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2010"
                        "volumen" => "182"
                        "paginaInicial" => "870"
                        "paginaFinal" => "876"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20448095"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the management of adults with hospital-acquired&#44; ventilator-associated&#44; and healthcare-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "American Thoracic Society &#40;ATS&#41; and Infectious Diseases Society of America &#40;IDSA&#41;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200405-644ST"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2005"
                        "volumen" => "171"
                        "paginaInicial" => "388"
                        "paginaFinal" => "416"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15699079"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Ricart"
                            1 => "C&#46; Lorente"
                            2 => "E&#46; Diaz"
                            3 => "M&#46;H&#46; Kollef"
                            4 => "J&#46; Rello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000094226.05094.AA"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "31"
                        "paginaInicial" => "2693"
                        "paginaFinal" => "2696"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nurses&#8217; implementation of guidelines for ventilator-associated pneumonia from the Centers for Disease Control and Prevention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Crit Care"
                        "fecha" => "2007"
                        "volumen" => "16"
                        "paginaInicial" => "28"
                        "paginaFinal" => "36"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence-based guidelines for the prevention of ventilator-associated pneumonia&#58; results of a knowledge test among European intensive care nurses"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2008.06.027"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2008"
                        "volumen" => "70"
                        "paginaInicial" => "180"
                        "paginaFinal" => "185"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An intervention to decrease catheter-related bloodstream infections in the ICU"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa061115"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2006"
                        "volumen" => "355"
                        "paginaInicial" => "2725"
                        "paginaFinal" => "2732"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Study of device use adjusted rates in health care-associated infections after implementation of bundles in a closed-model medical intensive care unit"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2009.06.016"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2010"
                        "volumen" => "25"
                        "paginaInicial" => "174"
                        "paginaFinal" => "178"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of a National Multimodal Intervention to Prevent Catheter-Related Bloodstream Infection in the ICU&#58; The Spanish Experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/CCM.0b013e3182923622"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2013"
                        "volumen" => "41"
                        "paginaInicial" => "2364"
                        "paginaFinal" => "2372"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Surveillance of Nosocomial Infections in Intensive Care Units&#46; Hospital in Europe Link for Infection Control through Sureveillance &#40;HELICS&#41;"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2013"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Should the diagnosis of ventilator associated pneumonia be improved&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2011.08.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2011"
                        "volumen" => "35"
                        "paginaInicial" => "578"
                        "paginaFinal" => "582"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Concordance between European and US case definitions of healthcare-associated infections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/2047-2994-1-28"
                      "Revista" => array:5 [
                        "tituloSerie" => "Antimicrob Resist Infect Control"
                        "fecha" => "2012"
                        "volumen" => "1"
                        "paginaInicial" => "28"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Grading quality of evidence and strength of recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.328.7454.1490"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2004"
                        "volumen" => "328"
                        "paginaInicial" => "1490"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "GRADE&#58; an emerging consensus on rating quality of evidence and strength of recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.39489.470347.AD"
                      "Revista" => array:6 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2008"
                        "volumen" => "336"
                        "paginaInicial" => "924"
                        "paginaFinal" => "926"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incorporating considerations of resources use into grading recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.39504.506319.80"
                      "Revista" => array:6 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2008"
                        "volumen" => "336"
                        "paginaInicial" => "1170"
                        "paginaFinal" => "1173"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Educational interventions for prevention of healthcare-associated infection&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/CCM.0B013E318165FAF3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2008"
                        "volumen" => "36"
                        "paginaInicial" => "933"
                        "paginaFinal" => "940"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reducing ventilator-associated pneumonia rates through a staff education programme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2004.03.002"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2004"
                        "volumen" => "57"
                        "paginaInicial" => "223"
                        "paginaFinal" => "227"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673602074421"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000029194.64089.0B"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2002"
                        "volumen" => "30"
                        "paginaInicial" => "2407"
                        "paginaFinal" => "2412"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/BF03016535"
                      "Revista" => array:6 [
                        "tituloSerie" => "Can J Anaesth"
                        "fecha" => "2005"
                        "volumen" => "52"
                        "paginaInicial" => "535"
                        "paginaFinal" => "541"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of a hospital-wide programme to improve compliance with hand hygiene&#46; Infection Control Programme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2000"
                        "volumen" => "356"
                        "paginaInicial" => "1307"
                        "paginaFinal" => "1312"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109703009252"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Surveillance and control of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> in Spanish hospitals&#46; A GEIH-SEIMC and SEMPSPH consensus document"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2008"
                        "volumen" => "26"
                        "paginaInicial" => "285"
                        "paginaFinal" => "298"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection&#58; 2009 Update by the Infectious Diseases Society of America"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/599376"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2009"
                        "volumen" => "49"
                        "paginaInicial" => "1"
                        "paginaFinal" => "45"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of daily chlorhexidine bathing on hospital-acquired infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1113849"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2013"
                        "volumen" => "368"
                        "paginaInicial" => "533"
                        "paginaFinal" => "542"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Targeted versus universal decolonization to prevent ICU infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1207290"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2013"
                        "volumen" => "368"
                        "paginaInicial" => "2255"
                        "paginaFinal" => "2265"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral hygiene with chlorhexidine in preventing pneumonia associated with mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Bras Pneumol"
                        "fecha" => "2008"
                        "volumen" => "34"
                        "paginaInicial" => "707"
                        "paginaFinal" => "714"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of ventilator-associated pneumonia&#58; analysis of studies published since 2004"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2007.06.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2007"
                        "volumen" => "67"
                        "paginaInicial" => "1"
                        "paginaFinal" => "8"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Topical chlorhexidine for prevention of ventilator-associated pneumonia&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000253395.70708.AC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2007"
                        "volumen" => "35"
                        "paginaInicial" => "595"
                        "paginaFinal" => "602"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized controlled trial and meta-analysis of oral decontamination with 2&#37; chlorhexidine solution for the prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/526438"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2008"
                        "volumen" => "29"
                        "paginaInicial" => "131"
                        "paginaFinal" => "136"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral hygiene with chlorhexidine on the prevention of ventilator-associated pneumonia in intubated patients&#58; a systematic review of randomized clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2010"
                        "volumen" => "135"
                        "paginaInicial" => "491"
                        "paginaFinal" => "497"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of ventilator-associated pneumonia with oral antiseptics&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(11)70127-X"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "845"
                        "paginaFinal" => "854"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/cc7967"
                      "Revista" => array:5 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2009"
                        "volumen" => "13"
                        "paginaInicial" => "R117"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An outbreak in an intensive care unit of a strain of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> sequence type 239 associated with an increased rate of vascular access device-related bacteremia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/511034"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2007"
                        "volumen" => "44"
                        "paginaInicial" => "493"
                        "paginaFinal" => "501"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> in an intensive care unit"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/648717"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2010"
                        "volumen" => "50"
                        "paginaInicial" => "210"
                        "paginaFinal" => "217"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Distribution of the antiseptic resistance genes qacA&#44; qacB and qacC in 497 methicillin-resistant and -susceptible European isolates of <span class="elsevierStyleItalic">Staphylococcus aureus</span>"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Antimicrob Chemother"
                        "fecha" => "2001"
                        "volumen" => "47"
                        "paginaInicial" => "896"
                        "paginaFinal" => "897"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Guidelines for the management of adults with hospital-acquired&#44; ventilator-associated&#44; and healthcare-associated pneumonia"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200405-644ST"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2005"
                        "volumen" => "171"
                        "paginaInicial" => "388"
                        "paginaFinal" => "416"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pneumonia in intubated patients&#58; role of respiratory airway care"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.154.1.8680665"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1996"
                        "volumen" => "154"
                        "paginaInicial" => "111"
                        "paginaFinal" => "115"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109704025069"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000266686.95843.7D"
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2007"
                        "volumen" => "35"
                        "paginaInicial" => "1543"
                        "paginaFinal" => "1549"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients&#58; a randomised trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(98)12251-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1999"
                        "volumen" => "354"
                        "paginaInicial" => "1851"
                        "paginaFinal" => "1858"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia&#58; a randomized study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "34"
                        "paginaInicial" => "396"
                        "paginaFinal" => "402"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of patient position on the incidence of ventilator-associated pneumonia&#58; a meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcrc.2008.09.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Crit Care"
                        "fecha" => "2009"
                        "volumen" => "24"
                        "paginaInicial" => "515"
                        "paginaFinal" => "522"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Semi-recumbent body position fails to prevent healthcare-associated pneumonia in Vietnamese patients with severe tetanus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.trstmh.2011.10.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Trans R Soc Trop Med Hyg"
                        "fecha" => "2012"
                        "volumen" => "106"
                        "paginaInicial" => "90"
                        "paginaFinal" => "97"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2010"
                        "paginaInicial" => "CD004127"
                        "itemHostRev" => array:3 [
                          "pii" => "S073510970402039X"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2010"
                        "paginaInicial" => "CD006904"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM200005183422002"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2000"
                        "volumen" => "342"
                        "paginaInicial" => "1471"
                        "paginaFinal" => "1477"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care &#40;Awakening and Breathing Controlled trial&#41;&#58; a randomised controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(08)60105-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2008"
                        "volumen" => "371"
                        "paginaInicial" => "126"
                        "paginaFinal" => "134"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of ventilator circuit changes on ventilator-associated pneumonia&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Care"
                        "fecha" => "2010"
                        "volumen" => "55"
                        "paginaInicial" => "467"
                        "paginaFinal" => "474"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of heat and moisture exchangers in preventing ventilator-associated pneumonia&#58; meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-004-2431-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2005"
                        "volumen" => "31"
                        "paginaInicial" => "5"
                        "paginaFinal" => "11"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of passive humidification on clinical outcomes of mechanically ventilated patients&#58; a meta-analysis of randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2007"
                        "volumen" => "35"
                        "paginaInicial" => "2843"
                        "paginaFinal" => "2851"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Changing heat and moisture exchangers every 48<span class="elsevierStyleHsp" style=""></span>hours does not increase the incidence of nosocomial pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/501631"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "1999"
                        "volumen" => "20"
                        "paginaInicial" => "347"
                        "paginaFinal" => "349"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Changing heat and moisture exchangers every 48<span class="elsevierStyleHsp" style=""></span>hours rather than 24<span class="elsevierStyleHsp" style=""></span>hours does not affect their efficacy and the incidence of nosocomial pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.152.5.7582295"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1995"
                        "volumen" => "152"
                        "numero" => "5 Pt 1"
                        "paginaInicial" => "1562"
                        "paginaFinal" => "1569"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prolonged use of heat and moisture exchangers does not affect device efficiency or frequency rate of nosocomial pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2000"
                        "volumen" => "28"
                        "paginaInicial" => "1412"
                        "paginaFinal" => "1418"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized clinical trial of extended use of a hydrophobic condenser humidifier&#58; 1 vs&#46; 7 days"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2002"
                        "volumen" => "30"
                        "paginaInicial" => "232"
                        "paginaFinal" => "237"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109705010235"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib0335"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2009"
                        "paginaInicial" => "CD000022"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients&#46; Systematic review of randomized&#44; controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2006.10.014"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2007"
                        "volumen" => "65"
                        "paginaInicial" => "187"
                        "paginaFinal" => "203"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care&#58; a randomised controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(03)14409-1"
                      "Revista" => array:7 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2003"
                        "volumen" => "362"
                        "paginaInicial" => "1011"
                        "paginaFinal" => "1016"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673604156900"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Decontamination of the digestive tract and oropharynx in ICU patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0800394"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2009"
                        "volumen" => "360"
                        "paginaInicial" => "20"
                        "paginaFinal" => "31"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units&#58; an open-label&#44; clustered group-randomised&#44; crossover study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(11)70035-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "372"
                        "paginaFinal" => "380"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SOD&#44; or oropharyngeal chlorhexidine to prevent pneumonia and to reduce mortality in ventilated patients&#58; which manoeuvre is evidence-based&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [ …5]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-010-1809-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2010"
                        "volumen" => "36"
                        "paginaInicial" => "1436"
                        "paginaFinal" => "1437"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subglottic secretion drainage for preventing ventilator-associated pneumonia&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjmed.2004.07.051"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "2005"
                        "volumen" => "118"
                        "paginaInicial" => "11"
                        "paginaFinal" => "18"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.08-0103"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2008"
                        "volumen" => "134"
                        "paginaInicial" => "938"
                        "paginaFinal" => "946"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib0375"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluation of continuous aspiration of subglottic secretion in an in vivo study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2004"
                        "volumen" => "32"
                        "paginaInicial" => "2071"
                        "paginaFinal" => "2078"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib0380"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A new technique of infection prevention in the intensive care unit by selective decontamination of the digestive tract"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Anaesthesiol Belg"
                        "fecha" => "1983"
                        "volumen" => "34"
                        "paginaInicial" => "209"
                        "paginaFinal" => "221"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib0385"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Selective decontamination of the digestive tract&#58; 13 years on&#44; what it is and what it is not"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [ …4]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "1996"
                        "volumen" => "22"
                        "paginaInicial" => "699"
                        "paginaFinal" => "706"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib0390"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.155.5.9154884"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1997"
                        "volumen" => "155"
                        "paginaInicial" => "1729"
                        "paginaFinal" => "1734"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib0395"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness and cost of selective decontamination of the digestive tract in critically ill intubated patients&#46; A randomized&#44; double-blind&#44; placebo-controlled&#44; multicenter trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.158.3.9712079"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1998"
                        "volumen" => "158"
                        "paginaInicial" => "908"
                        "paginaFinal" => "916"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib0400"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.12-1361"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2013"
                        "volumen" => "143"
                        "paginaInicial" => "1219"
                        "paginaFinal" => "1225"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care&#58; an observational&#44; multicentre cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [ …6]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(10)70314-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "181"
                        "paginaFinal" => "189"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack82380"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0245" class="elsevierStylePara elsevierViewall">This manuscript is dedicated to the memory of Dr&#46; Mar&#237;a Jes&#250;s L&#243;pez Pueyo&#46;</p> <p id="par0250" class="elsevierStylePara elsevierViewall">We thank Yolanda Agra &#40;QAA&#41; and the regional healthcare authorities for their commitment&#44; allocation of resources and organizational support of &#8220;Zero VAP&#8221;&#46; The regional and local medical and nurse coordinators deserve mentioning for their outstanding efforts and commitment&#46; Our thanks go also to the intensivists and critical care nurses of the participating units&#44; whose dedication to the implementation of the proposed measures was decisive in actually making &#8220;Zero VAP&#8221; possible&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/21735727/0000003800000004/v1_201405150137/S217357271400023X/v1_201405150137/en/main.assets"
  "Apartado" => null
  "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003800000004/v1_201405150137/S217357271400023X/v1_201405150137/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357271400023X?idApp=WMIE"
]
Article information
ISSN: 21735727
Original language: English
DOI:10.1016/j.medine.2013.12.001
The statistics are updated each day
Year/Month Html Pdf Total
2024 November 32 15 47
2024 October 228 73 301
2024 September 196 53 249
2024 August 215 63 278
2024 July 187 36 223
2024 June 251 92 343
2024 May 170 73 243
2024 April 233 62 295
2024 March 443 57 500
2024 February 504 77 581
2024 January 675 60 735
2023 December 459 70 529
2023 November 650 111 761
2023 October 599 151 750
2023 September 397 99 496
2023 August 218 44 262
2023 July 197 49 246
2023 June 175 41 216
2023 May 191 60 251
2023 April 175 59 234
2023 March 225 63 288
2023 February 147 47 194
2023 January 125 45 170
2022 December 163 40 203
2022 November 175 67 242
2022 October 171 89 260
2022 September 191 48 239
2022 August 198 55 253
2022 July 212 69 281
2022 June 197 76 273
2022 May 197 63 260
2022 April 203 64 267
2022 March 222 80 302
2022 February 234 71 305
2022 January 290 81 371
2021 December 387 134 521
2021 November 376 149 525
2021 October 361 144 505
2021 September 277 85 362
2021 August 213 87 300
2021 July 248 86 334
2021 June 319 113 432
2021 May 323 128 451
2021 April 1088 244 1332
2021 March 573 207 780
2021 February 277 102 379
2021 January 229 67 296
2020 December 259 64 323
2020 November 540 113 653
2020 October 437 116 553
2020 September 514 106 620
2020 August 389 87 476
2020 July 460 71 531
2020 June 451 111 562
2020 May 430 106 536
2020 April 666 81 747
2020 March 314 81 395
2020 February 720 174 894
2020 January 593 133 726
2019 December 505 132 637
2019 November 1481 224 1705
2019 October 1951 237 2188
2019 September 1185 234 1419
2019 August 676 131 807
2019 July 519 154 673
2019 June 362 121 483
2019 May 445 142 587
2019 April 303 87 390
2019 March 222 111 333
2019 February 154 102 256
2019 January 197 59 256
2018 December 149 94 243
2018 November 261 122 383
2018 October 104 49 153
2018 September 45 39 84
2018 August 114 51 165
2018 July 124 47 171
2018 June 145 51 196
2018 May 29 20 49
2018 April 50 64 114
2018 March 76 56 132
2018 February 55 69 124
2018 January 69 40 109
2017 December 60 60 120
2017 November 63 62 125
2017 October 78 71 149
2017 September 62 55 117
2017 August 43 40 83
2017 July 40 40 80
2017 June 66 57 123
2017 May 59 66 125
2017 April 68 57 125
2017 March 71 71 142
2017 February 38 54 92
2017 January 44 34 78
2016 December 50 30 80
2016 November 45 37 82
2016 October 68 52 120
2016 September 57 42 99
2016 August 33 5 38
2016 July 30 7 37
2016 June 1 0 1
2016 February 1 0 1
2015 December 2 0 2
Show all

Follow this link to access the full text of the article

Subscribe to our newsletter

Publish in
Medicina Intensiva
Free access articles
Clinical efficacy of oXiris-continuous hemofiltration...
10.1016/j.medine.2024.09.012
Impact of high-flow oxygen therapy via high velocity nasal...
10.1016/j.medine.2024.05.017
Multimedia
Complicated early prosthetic aortic valve infective endocarditis
More images.
Idiomas
Medicina Intensiva (English Edition)
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?