Effectiveness of Oral Care with Antiseptics in Preventing Ventilator Associated Pneumonia

This systematic review evaluates the effectiveness of oral care with antiseptics in preventing ventilator associated pneumonia in patients on mechanical ventilation.

Running head: VENTILATOR ASSOCIATED PNEUMONIA
VENTILATOR-ASSOCIATED PNEUMONIA
Student Name:
Student Number:
Student Coordinator:
Subject Name:
Due Date:

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ASSESSMENT 3B: PROJECT FINAL OUTPUT
TITLE OF SYSTEMATIC REVIEW
A summary of systematic review on effectiveness of oral care with
antiseptics to prevent ventilator associated pneumonia in patients on
mechanical ventilation

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Executive Summary:
Background: The report revolves around the condition of Ventilator Associated Pneumonia
that is considered as the most prevalent nosocomial infection with a high mortality rate.
Pseudomonas aeruginosa and Staphylococcus aureus are the microorganisms responsible for
causing ventilator Associated Pneumonia. The above mentioned pathogens reside in the oral
cavity of the patient thus the patient receiving mechanical ventilation are not allowed to
consume food orally there reducing the overall salivary secretions. Various interventions are
used to overcome the issue of ventilator associated pneumonia.
Objectives: The primary focus of this study is to evaluate the effectiveness of oral care
intervention in preventing the condition of ventilator associated pneumonia. In this procedure
the mouth of the patient is kept clean and devoid of any bacterial contamination.
Inclusion criteria: Various systematic study is conducted that will highlight the
effectiveness of using oral care as the intervention in preventing ventilator associated
pneumonia for the patient on mechanical ventilation and is included in the study. The paper
focusing on the patient present ion mechanical ventilation without any gender and age
limitation are included in the study.
Types of Participants: The participants included in the study were critically ill-patient who
were on mechanical ventilation irrespective of their sex or age for approximately 48 hours or
more.
Types of intervention: The intervention will be included for the study focusing on
effectiveness of oral care with antiseptic in preventing ventilator associated pneumonia for
patient on mechanical ventilation. The study focusing on any other intervention other than
oral care with antiseptic will be omitted from the study. A control group is established to

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relate and compare the articles based on systematic review and accordingly the outcomes will
be assessed.
Type of Studies: All systematic review articles are included in this study.
Outcome Measure: The outcome was evaluated from the prevalence rate of VAP, total
period of hospital stay, total period of mechanical ventilation and patient present in intensive
care unit.
Search Strategy: Electronic databases are used as the search strategies to extract the relevant
articles. MEDLINE, COHRANE LIBRARY, CINAHL PLUS and JONNA BRIGGS
INSTITUTE are the electronic databases used in the study. Appropriate keywords and terms
are used and the search is limited to the peer-reviewed articles, English language and latest
publication year.
Methodological quality: In order to assess the quality of methodology of the study a critical
appraisal tool is used. AMSTAR checklist tool is used to assess the quality of extracted
journal articles and accordingly the data is extracted from the most relevant journal articles
used in the study.
Data extraction: The data were extracted in this systematic review study by using various
specific key words. The keywords were precise and accurate and explained specific
intervention related to VAP and extracted outcome that would fulfil the objective of the
study.
Data synthesis: This systematic review offered the data synthesis in a narrative form that
included exploration and discussion of the result which focused on assessing the efficiency of
oral mouth care using chlorhexidine.

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Result: Result is included based on the relevance of the article and the findings that each
article suggest. It was extracted that if 2% of chlorhexidine is used by the patient four times a
day associated with effective oral mouth care it will help the patient to overcome from the
issue of ventilator associated pneumonia.
Conclusion: From this systematic review of research article it was observed that oral mouth
care associate with chlorhexidine at 2% concentration taken three times per day is proved to
be highly effective in treating and preventing the risk of ventilator associated pneumonia
(VAP).

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Table of Contents
BACKGROUND:......................................................................................................................7
OBJECTIVE............................................................................................................................10
CONDITIONS FOR CONSIDERING STUDIES FOR THIS REVIEW................................10
Types of studies:..................................................................................................................10
Types of participants:...........................................................................................................10
Types of interventions:.........................................................................................................10
Control group in the study:..................................................................................................11
Types of outcome measures.................................................................................................11
Search Strategy.........................................................................................................................11
Methods of the review..............................................................................................................13
Valuation of methodology quality:......................................................................................13
Data extraction.....................................................................................................................13
Data synthesises...................................................................................................................14
Result........................................................................................................................................14
Paper selection process........................................................................................................14
Discussion................................................................................................................................18
Conclusion................................................................................................................................20
Implication for practice............................................................................................................21
Implication for research...........................................................................................................21
References................................................................................................................................22
Appendixes...............................................................................................................................28

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Appendix A: Proposed Timeframe..........................................................................................28
Appendix B:.............................................................................................................................29
Appendix C: List of excluded articles......................................................................................30
Appendix D: AMSTAR Critical appraisal form......................................................................33
Appendix E: Data Extraction Form..........................................................................................34
Appendix F: Gantt chart...........................................................................................................36

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BACKGROUND:
Ventilator Associate d Pneumonia (VAP) is considered as the most common
nosocomial contaminations with high mortality rate (Sadasivan et al., 2018). VAP endures to
be an important medicinal issue with high death rate that range among 33% to 50% in spite of
the current developments in the treatment and diagnosis of Ventilator Associated pneumonia
(Villar et al., 2016). The microbes responsible for the development of VAP are Pseudomonas
aeruginosa and staphylococcus aureus. The above mentioned pathogens leading to the
condition of VAP resides in the oral cavity or mouth of the patients, who are under critical
care condition (Haghighi et al., 2017). Due to lack of oral consumption of food among
patients living in mechanical ventilation, the amount of salivary secretions is reduced in such
patients that decreases the self-cleaning method of oral cavity in mouth that is responsible for
increasing the overall bacterial count in such patient. Therefore, it leads to colonisation of
bacteria in oropharynx (Kaya et al., 2017). Hence, it is evident from the result that
orpharyngeal tract is the primary cause of ventilator associated pneumonia (VAP).
Various interventions are present that can be used to overcome or treat the condition
of ventilator associated pneumonia and primarily focus on the intervention of oral cares
associated antiseptics in the patients suffering from this condition in mechanical ventilation.
The intervention of oral care is used as it was seen that ventilator associated pneumonia takes
place or affect people through their endotracheal tube, micro aspiration and open mouth tube
during their oral mouth secretions (Chacko et al., 2017). According to Yeganeh et al., (2019)
poor suctioning and bad oral care is connected with the high or increased prevalence rate of
ventilator associated pneumonia (VAP). There are various types of complications present in
case of ventilator pneumonia that includes empyema, lung abscess and bacteria. The risk of
Ventilator Associated Pneumonia is primarily developed because of different elements

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associated to mouth or oral care that includes growth or development of plague formation,
micro-aspiration of oral secretions and development of bacterial colonies (Lev et al., 2015).
The concept of oral care or health is considered as a crucial measure in inhibiting the
incidence of ventilator associated pneumonia (VAP) by decreasing the total amount of
microorganism present in the mouth of the patient (Bouadma et al., 2018). The above
mentioned reason describes the necessity to evaluate the oral mouth care practices in order to
decrease the danger of VAP. The concept of VAP also comprises of following key terms and
their definitions:
Ventilator Associated Pneumonia (VAP): Ventilator associated pneumonia is defined as the
lung infection type especially in case of patient who are residing on breathing machine like
mechanical ventilation in hospitals. Centres for Disease Control and Prevention (CDC) had
described that it is a kind of pneumonia condition, which progresses within 48 hours of the
patient admission or after the patients are dependent or present on breathing machine like
mechanical ventilation (Batra et al., 2018).
Oral Care: Oral hygiene or care is defined as the exercise that aid the patient to keep their
mouth hygienic and maintain the hygiene, hence allowing the patient to be free from different
types of oral cavity infections or microorganisms.
Prevention: In order to maintain a good level of hygiene prevention plays a major role that is
defined as an act or action of stopping something from developing or arising that can create
problem among the patient and affect their health. Hence, prevention will assists the patient
in preventing and maintain their health condition.
Antiseptics: An antiseptic is a substance that prevent or slows down the expansion of
harmful micro-organism that is present in the hospital surrounding and can result in the
development of infection.

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Ventilator Associated Pneumonia is considered as the significant issues among the
population of patients admitted in the hospital because of high hospital budgets, high
mortality and morbidity rate and longer stay in hospital (Tokmaji et al., 2015). Importance on
the concept of oral hygiene or oral care is increasing among the population associated with
consumption of antiseptics especially for the patient on mechanical ventilation. The patient
who are on mechanical ventilation for approximately 48 hours or more are at higher risk of
developing ventilator associated infection. There are various studies that focus on different
interventions or preventive strategies to reduce the elevated risk of nosocomial infections and
help the patient to prevent VAP. The studies included are both supportive and conflicting in
nature thus highlighting the strength and weakness of the recommended intervention that is
used for preventing ventilator associated pneumonia. Systematic review was conducted for
this study that had focused on the concept of oral care associated with antiseptic for
preventing the onset of ventilator associated pneumonia and the results obtained from
systematic review stated that oral mouth care is effective in preventing ventilator associated
pneumonia when associated with antiseptics (Bouadma and Klompas, 2018). From the
systematic review analysis, contrary results were also observed, which stated that oral mouth
care associated with antiseptic is not very operative in inhibiting ventilator associate
pneumonia. Hence, it is very challenging to classify the intervention as the most effective
option for preventing VAP. Meta-analysis and systematic review method of research study is
being largely adapted by the people for evaluating and combining the positive effect of
intervention in preventing ventilator associated pneumonia (Guler and Turk, 2018). From the
meta-analysis and systematic review of VAP studies it revealed that consuming 2%
chlorhexidine is an effective strategy for preventing ventilator associated pneumonia (VAP)
however few studies also revealed that consuming 0.12% and 0.2% of chlorhexidine
associated with oral care is effective in preventing ventilator associate pneumonia (Zhang et

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al., 2017). In systematic review study both control group and intervention group were present
and were provided with chlorhexidine with oral care. The result were varying among the
people present in the group because of different age group, complexity of condition and level
of intervention with the length of stay in hospitals (Longti et al., 2015).
OBJECTIVE
The primary purpose or objective of conducting the systematic review study is to
recognize, evaluate and encapsulate the efficiency of oral mouth care associated with
antiseptics in order to avoid the condition of ventilator associated pneumonia (VAP) among
patients present on breathing chamber like mechanical ventilation for approximately 48 hours
or more.
CONDITIONS FOR CONSIDERING STUDIES FOR THIS REVIEW
Types of studies:
The review primarily consider the studies that focus on systematic review method to
evaluate the effectiveness and efficiency of oral mouth care associated with chlorhexidine
that is an antiseptic in order to inhibit ventilator associated pneumonia (VAP) within the
patients present on the mechanical ventilation for approximately 48 hours or more.
Types of participants:
The systematic review conducted for this study will include articles that is focused on
critically ill-patient present on the mechanical ventilation with no limitation of particular age
group or sex. The study will exclude articles that includes extremely ill-patients but have not
undergone or experience mechanical ventilation. The list of excluded articles are included in
Appendix- C.

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Types of interventions:
The type of intervention involved in this systematic review is oral mouth care and
evaluating the efficiency of oral mouth cares associated with chlorhexidine in reducing the
incidence of ventilator associated pneumonia among patients present on the mechanical
ventilation (Glurich et al., 2019). The intervention included in this study will not compare
any other type of oral mouth care or standard of oral care exercise. Systematic articles that
consists of any other type of interventions will be excluded from this study concentrating on
the inhibition of VAP.
Control group in the study:
Control group included in this study from the systematic review will focus and
include ‘oral mouth care associated with chlorhexidine’. Chlorhexidine is the most effective
antiseptic used for treating the condition of ventilator associated pneumonia (Lee et al.,
2019). Hence, this systematic review study will contain articles that estimate the practice of
consuming oral mouth care associated with antiseptics in order to inhibit ventilator associated
pneumonia.
Types of outcome measures
The primary outcome analysed and collected in this study focused on the prevalence
or incidence rate and mortality rate of ventilator associated pneumonia (VAP). It was
observed that the rate of incidence was high among the patient who were admitted in the
emergency and ICU department of the hospital and present on mechanical ventilation. Hence,
using such patient for trails was required to achieve relevant and accurate outcome. The
studies focusing on the prevalence rate of VAP in acute care patients present on the
mechanical ventilation were considered and evaluated for determining the efficiency of oral
mouth care associated with chlorhexidine (Kaneoka et al., 2015).

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Search Strategy
Search strategy is defined as the method of organising the significant key terms and
search those specific terms in database in order to retrieve the accurate result that can be
further used to either publish it or not publish it in systematic reviews. Search strategy is an
organised method that combine the accurate key terms present in the research question of the
study and further evaluate the result based on those search terms and keywords (Hurley,
2018). This study also comprise of such relevant keywords that will be examined or searched
in different databases and help the researcher to evaluate and determine the result focusing if
oral mouth care associated with chlorhexidine is effective in preventing the condition of
ventilator-associated pneumonia. The database included or considered in this study is as
follows:
 MEDLINE
 CINAHL PLUS
 COHRANE LIBRARY
 JONNA BRIGGS INSTITUTE
The relevant data in this study is searched by not only using keywords but also
including different combination or grouping of keywords. By using these combination of
relevant keywords, a large number of studies can be extracted that would become difficult for
the researcher to evaluate the result hence, the search is restricted to certain limitation such
the study published in English language will be considered, latest publication year will be
considered that is peer reviewed, full text articles are used and the participants involved must
be human only (Rabello, Araujo & Magalhaes, 2018). The articles are chosen from the recent
studies that is not more than 5 years old and hence will help the researcher to identify the
latest information regarding the intervention and accordingly focus on the modified practice

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that altered with time. In Appendix-B, a search strategy example is explained using CINHAL
PLUS database that is included in this study.
Methods of the review
Valuation of methodology quality:
The studies designated were evaluated or evaluated in AMSTAR tool. The assessment
of multiple systematic reviews (AMSTAR) is a most widely used tool that is primarily used
for investigating the quality of methodology included in systematic review articles and hence
is considered as the critical appraisal tool, which include both randomised and non-
randomised study for identifying the quality of systematic review (Chang & Schibler, 2016).
AMSTAR checklist is used in this particular study, which comprises of selected articles that
is retrieved and will be evaluated for obtaining the quality of methodology before including
the articles in this review (Rabello et al., 2018). AMSTAR tool is considered as a trustworthy
tool that consists of 11 brief standard items that will help the researcher to evaluate the
superiority of methodology in systematic reviews articles (Katrak et al., 2018). Those 11
items present in AMSTAR checklist will elaborate the content of the articles that will give a
brief idea regarding the strength and weakness of methodology part of the articles. The total
amount ranges in between 0 to 11 that will evaluate the quality of methodology, where the
range of 8-11 will state high quality research methodology, 5-7 will state medium quality
research methodology and 0-4 will state low quality research methodology. The AMSTAR’s
score is obtained and considered by using option 1 for every ‘yes’ standard and option 0 or no
score for every ‘no’, ‘not applicable’ and ‘can’t answer’ standard. The total AMSTAR’s
score is then calculated by adding the total number obtained in each research article and then
determining which articles consists of high quality methodology part. The AMSTAR critical
appraisal form used in this systematic review is delivered in Appendix D.

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Data extraction
Data was extracted using various studies that focused on the condition of ventilator
associated pneumonia and its intervention of oral mouth care associated with chlorhexidine.
The inclusion articles are included in this data extraction tool and the articles not applicable
for this review were considered as excluded articles (Spreadborough et al., 2016). Data
extraction in this systematic review will comprise of definite information about populace,
intervention, study methods and research consequences, which is important for analysing
question and definite aims. Data selection tool was included in this review that is explained in
Appendix-E.
Data synthesises
Findings obtained from systematic review were offered in a narrative method by using
figures and tables. Data synthesis was conducted by assessing the efficiency of the selected
intervention either by comparing or not comparing with oral mouth care with any kind of
prevention practices (Kim, Ryu & Kim, 2019). Result exploration method was used to
retrieve the relevant information required in this study. Data synthesis also comprised the
superiority of evidence extracted from the study and the implication of those evidence in
general research and practice.
Result
Paper selection process
The research article included in this study were evaluated from CINAHL tool and
were further included in this study were only 7 systematic review articles were eligible and
fulfilling the inclusion criteria and 16 articles were rejected after analysing the review. Full
text 7 systematic review articles were thus obtained for further review and the studies

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Total number of articles
retrieved originally from
CINAHL PLUS (n=27)
Articles recovered for
detailed examination
(n=19)
Quantity of
duplicate article
removed (n=3)
(
Complete articles
recovered for added
examination (n= 12)
Complete articles
retrieved for further
examination (n= 9)
Papers included in
review (n=7)
Irrelevant articles
after appraisal of
abstract (n=7)
Papers excluded for not
fulfilling the criteria (n=
4) for VAP prevention
bundles, oral care using
other antiseptic and
systematic analysis.
Papers excluded
after quality
assessment (n= 2)
included in those articles were published in English language in between the year 2015-2019
(Vilele et al., 2015).
Flow diagram of the paper selection process
Subject Collection and characteristics: The 7 included systematic review articles delivered
data concerned with 1566 subjects. These subjects were provided with chlorhexidine (n=
656) or control (n= 689) groups. Patients who were involved in this study were estimated to
involve in mechanical ventilation and should be present in this breathing machine for

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approximately 48 hours or more. The subjects involved in this study were majorly adults but
few studies also focused on children, which means that the approximate age of the adults
more than eighteen and children were less than 15 (Ory et al., 2017). The patient admitted to
the intensive care unit (ICU) and emergency department (ED) were included in the study
were few studies involved patient trials present in paediatric ICU. One study trail was
conducted among the patient present in cardiothoracic ICU. The rest study trail was
conducted among the patient present in mixed ICU department and clinical surgical ICU
department. Chlorhexidine was given to the patient involved in the trail of different
concentration like 0.12%, 1%, and 0.2% and 2%. Different methods were used to supply
chlorhexidine to those patient including jelly, foam, oral wash solution and gel (Speck et al.,
2016). The chlorhexidine frequency was also varying in different studies were in some study
single dose was given to the patient in different interval of time. Systematic review method
was used to evaluate these trials that will demonstrate the efficiency of oral mouth care
exercise with different chlorhexidine concentration in decreasing the incidence of ventilator-
associated pneumonia (VAP) (Nayak, Norohna & Chakrabarthy, 2018).
Consequence of oral mouth care associated with chlorhexidine on decreasing VAP:
From the 7 systematic review articles included in the study indicated that use of
chlorhexidine were effective in treating ventilator associated pneumonia including both 72
and 48 hours from hospital admittance correspondingly p=0.018 and p=0.004. It was
observed that 60% of the patient in control group had developed the risk of VAP within 48
hours of staying in mechanical ventilation as compared to the intervention group (Hellyer et
al., 2016). 28% of the patient included in intervention group had developed the risk of VAP
within 48 hours of staying in mechanical ventilation. Another systematic review trial
exhibited that no substantial difference was noted in prevalence of VAP among control group
and chlorhexidine. The study revealed that 30% of children included in chlorhexidine group

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had less risk of developing ventilator-associated pneumonia when compared to the control
group where the risk of developing VAP was 36%. The dosage of chlorhexidine had no such
effect on paediatric ICU death rate (p=0.25), total hospital stay period (p=0.2) and total ICU
stay period (p=0.17). The related chlorhexidine effect was demonstrated in another
systematic review trial. The oral consumption of chlorhexidine flops to enable important
prevention high prevalence rate of ventilator-associated pneumonia (Bardia et al., 2019).
Additionally, it was also seen that chlorhexidine is operative in decreasing the oral bacterial
colonization when likened to the monotonous care using thymol (p<0.001). From the study it
was also evident that the overall threat of oral colonization of bacteria was three times greater
in the control group as they used normal oral care method when compared to the intervention
group who used chlorhexidine associated with oral mouth care. From certain systematic
review trials it was noted that oral mouth care associated with chlorhexidine was beneficial in
preventing the prevalence rate of ventilator-associated pneumonia (VAP). It demonstrated
that growth of VAP infection was greater in the patient involved in control group who were
given with normal oral mouth care as compared to the patient in intervention group who were
given oral mouth care associated with chlorhexidine 65% vs. 39% respectively p=0.3
(Maertens, Blot & Blot, 2018). The above result is supported with another study that
exhibited that chlorhexidine was not very effective in preventing ventilator associate
pneumonia as compared to sodium bicarbonate.
Result of chlorhexidine concentration and incidence of use in decreasing VAP: The
investigation of another systematic review trial exhibited that chlorhexidine inhibits the
growth of ventilator-associated pneumonia (VAP) when given concentration of 2%
chlorhexidine and consuming chlorhexidine 3 times per day. The efficiency of oral mouth
care associated with chlorhexidine was well revealed in other systematic review trials that
indicated the necessity to apply this exercise in clinical regions particularly in intensive care

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units (ICU) (Liu et al., 2018). The systematic review conducted by (201) specifies that
prevalence of ventilator- associated pneumonia (VAP) conveyed as 45/900 ventilator days
associated with 1.5% chlorhexidine and 39/900 ventilator days associated with the control
group. The death rate was conveyed alike in both the groups (p=.76). Also, the concept of
tooth brushing associated with 0.15% chlorhexidine was considered highly effective in
preventing the prevalence rate of ventilator-associated pneumonia (VAP). Significant
reduction in prevalence rate of ventilator associated pneumonia was observed during tooth
brushing in the patient on mechanical ventilation (p=0.02) (Schreiber et al., 2018). No major
difference was observed in the mortality rates of patient present in ICU with longer or shorter
period of hospital stay (p=0.013). Hence, from the overall analysis it was evident that oral
mouth care associated with 2% chlorhexidine were effective in preventing the condition of
ventilator associated pneumonia.
Discussion
The systematic review conducted in this study delivers the complete assessment
concerning the influence of various kinds of oral mouth care practices associated with diverse
chlorhexidine concentrations in order to prevent the incidence rate of ventilator-associated
pneumonia (VAP) (Righy et al., 2017). From the result, it was observed that the efficiency of
oral mouth care associated with chlorhexidine inhibiting VAP was influenced by different
factors like age of the patient, frequency and concentration of chlorhexidine. This systematic
review revealed that oral mouth care associated with chlorhexidine is proved to be operative
in inhibiting ventilator associated pneumonia in adult patients. Though it lacked to exhibit
any influence in preventing growth of ventilator associated pneumonia among infants and
new born. The primary reason for this inefficiency occurred as no paediatric trials included
the consumption of 2% chlorhexidine associated with incidence of 3 times per day. Hence, it
is established that accurate frequency and dose of chlorhexidine will exhibit increased rate of

19VENTILATOR-ASSOCIATED PNEUMONIA
efficiency in oral mouth care associated with chlorhexidine for preventing ventilator
associated pneumonia (Klompas, 2017). The analysis exhibited that the concentration of
0.12% chlorhexidine and 0.2% chlorhexidine has failed in being effective for preventing the
high incidence rate of ventilator associated infection within adult patients.
The selected systematic review trials defined that the clinical significance and
effectiveness of using of chlorhexidine for oral mouth care in decreasing ventilator-associated
pneumonia in patients present on mechanical ventilation for approximately 48 hours or more
was effective. Hence, it is established that single use of chlorhexidine in oral cavity will
significantly reduce the risk of hospital acquired pneumonia infection among ICU patients
(Scannapieco & Harris, 2016). However, it was observed in few cases that 0.12% of
chlorhexidine is unsuccessful in modifying the prevalence rate of ventilator-associated
pneumonia (VAP) present on children in mechanical ventilation. It was also evident that 2%
of chlorhexidine concentration is highly effective in decreasing the high rate of prevalence of
ventilator-associated pneumonia for patient who were admitted to the hospital. It was also
observed in few cases that 0.12% of chlorhexidine concentration also assisted in reducing the
high rate of prevalence of ventilator-associated pneumonia (VAP). The influence of
chlorhexidine and its positive health result is different among diverse age groups that consists
of children, adults and elder people (Timsit et al., 2017).
From the result analysis it was observed that the single dose of chlorhexidine is
effective in treating patient present on mechanical ventilation when given chlorhexidine three
times per day as the result of chlorhexidine is present in the human body for more than 12
hours or 12-14 hours. However, few studies exhibited that result of chlorhexidine is present
in the human body for more than 12 hours approximately, which specifies that efficiency of
chlorhexidine is reliant on its own anti-microbial action (Lewis et al., 2016). Very limited
studies were present that demonstrated the efficiency of oral mouth care associated with 2%

20VENTILATOR-ASSOCIATED PNEUMONIA
of chlorhexidine when consumed 4 times per day. Hence, it was obvious that the influence of
chlorhexidine for preventing or reducing ventilator associated pneumonia has been important
if more number of trials were conducted that used 2% of chlorhexidine concentration and
consumed three times per day. Different concentration of chlorhexidine was used in different
studies that exhibited diverse result depending on the consumption of chlorhexidine.
Additionally, the mixture of diverse interventions had assisted to achieve better outcomes
(Michaud et al., 2016).
Certain limitation was also present in this systematic review trails such as year of
publication. As the search was limited to last five years of publication, it was highly possible
that few older research articles might contain important and useful information that is missing
from the recent articles and the researcher could not think and catch up to those ideas
(Silvestri et al., 2017). The historical perspective of chlorhexidine consumption was missed
by using the recent years of article and any assumption made from historical perspective
could not be interpreted as no trails were included that would exhibit oral mouth care
associated with chlorhexidine in preventing ventilator associated pneumonia (VAP).
Correspondingly, the included trials concentrated on evaluation of different intervention
group with absence of oral care or presence of normal oral care as an alternative of judgement
between dissimilar frequencies and doses of chlorhexidine (Leone et al., 2018). The diverse
age group of the patient included in the study was also a limitation as it was becoming
difficult to evaluate the outcome of intervention among different population due to different
medical condition, response of health outcome and reaction from the provided intervention.
Conclusion
Hence from this systematic review of research article it was observed that oral mouth
care associate with chlorhexidine at 2% concentration taken three times per day is proved to

21VENTILATOR-ASSOCIATED PNEUMONIA
be highly effective in treating and preventing the risk of ventilator associated pneumonia
(VAP). The study also discovered that chlorhexidine is more effective form of antiseptic
when compared to some other type of antiseptic like Listerine ad sodium bicarbonate.
Implication for practice
The evidence collected and observed from the above result stated that oral health care
associated with chlorhexidine is important for various practical purpose as compared to
different oral mouth care intervention as it is highly effective in treating ventilator associated
pneumonia for the patient who ate admitted to hospitals for approximately 48 hours or more.
The chlorhexidine solution is also easily available and the patient can find it in the
pharmaceutical shop and consume it for preventing the condition of ventilator associated
pneumonia. Hence, the chlorhexidine solution is easy to consume by the patient and is
considered as the best oral mouth care alternative.
Implication for research
The research findings observed from the studies were inferred carefully due to high
heterogeneity and was observed that oral mouth care associated with 2% of chlorhexidine
solution is beneficial for preventing the incidence rate of ventilator associated pneumonia
among patient present in mechanical ventilation. The rate of risk infection is high among
patient admitted in the emergency and ICU department hence, the health care professionals
can use this intervention strategy and help in preventing the condition of ventilator-associated
pneumonia. Further detail review is still required because not enough trails are conducted
that is evaluating the efficiency of 2% chlorhexidine consumed 4 times/day. Detail analysis
of the study needs to be done on evaluation between diverse chlorhexidine concentrations
with dissimilar frequencies of chlorhexidine.

22VENTILATOR-ASSOCIATED PNEUMONIA
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Care Model: Pneumonia and Oral Health. In Integration of Medical and Dental Care
and Patient Data (pp. 123-139). Springer, Cham.
Guler, E. K., & Turk, G. (2018). Oral chloorhexide against ventilator- associated pneumonia
and microbial colonization in intensive care patients. Western Journal of Nursing
Research, 1-19
Haghighi, A., Shafipour, V., Bagheri-Nesami, M., Baradari, A., & Charati, J. (2017). The
impact of oral care on oral health status and prevention of ventilator- associated
pneumonia in critically ill patients. Australian Critical Care,30 (1), 69-73.

23VENTILATOR-ASSOCIATED PNEUMONIA
Hellyer, T. P., Ewan, V., Wilson, P., & Simpson, A. J. (2016). The Intensive Care Society
recommended bundle of interventions for the prevention of ventilator-associated
pneumonia. Journal of the Intensive Care Society, 17(3), 238-243.
Hua, F., Xie, H., Worthington, H. V., Furness, S., Zhang, Q., & Li, C. (2016). Oral hygiene
care for critically ill patients to prevent ventilator‐associated pneumonia. Cochrane
Database of Systematic Reviews, (10).
Hurley, J. C. (2018). Paradoxical Acinetobacter-associated ventilator-associated pneumonia
incidence rates within prevention studies using respiratory tract applications of topical
polymyxin: benchmarking the evidence base. Journal of Hospital Infection, 100(1),
105-113.
Kaneoka, A., Pisegna, J. M., Miloro, K. V., Lo, M., Saito, H., Riquelme, L. F., ... &
Langmore, S. E. (2015). Prevention of healthcare-associated pneumonia with oral care
in individuals without mechanical ventilation: a systematic review and meta-analysis
of randomized controlled trials. infection control & hospital epidemiology, 36(8),
899-906.
Kaya, H., Turan, Y., Aydin, G., O., Tunali, Y., Yuce, N., Gurbuz, S., & Tosun, K. (2017).
Effects of oral care with preventing ventilator- associated pneumonia in neurosurgical
care unit patients. Applied Nursing Research, 33,10-14. Journal homepage:
www.elsever.com/locate/apnr
Kim, N. Y., Ryu, S., & Kim, Y. H. (2019). Effects of Oral Care Using Chlorhexidine
Gluconate on Ventilator-associated Pneumonia and Mortality: A Systematic Review
and Meta-analysis. Korean Journal of Adult Nursing, 31(2), 109-122.
Klompas, M. (2017). What is new in the prevention of nosocomial pneumonia in the ICU?.
Current opinion in critical care, 23(5), 378-384.

24VENTILATOR-ASSOCIATED PNEUMONIA
Lee, L., V., D., Hill, A., M., & Patman, S. (2017). Efficiency of a respiratory physiotherapy
intervention for intubation and mechanically ventilated adult with community
acquired pneumonia: a systematic review protocol. Systematic Review Protocol, 15
(6), 1508-1511.
Lee, S., Lighvan, N. L., McCredie, V., Pechlivanoglou, P., Krahn, M., Quiñonez, C., &
Azarpazhooh, A. (2019). Chlorhexidine-Related Mortality Rate in Critically Ill
Subjects in Intensive Care Units: A Systematic Review and Meta-Analysis.
Respiratory care, 64(3), 337-349.
Leone, M., Bouadma, L., Bouhemad, B., Brissaud, O., Dauger, S., Gibot, S., ... & Luyt, C. E.
(2018). Hospital-acquired pneumonia in ICU. Anaesthesia Critical Care & Pain
Medicine, 37(1), 83-98.
Lev, A., Aied, A.S., & Arshed, S. (2015). The effect of different oral hygiene treatment on
the occurrence of ventilator associated pneumonia in ventilated patients. Journal of
infection prevention, 16 (2), 76-81.
Lewis, S. R., Butler, A. R., Evans, D. J., Alderson, P., & Smith, A. F. (2016). Chlorhexidine
bathing of the critically ill for the prevention of hospital‐acquired infection. Cochrane
Database of Systematic Reviews, (6).
Liu, C., Cao, Y., Lin, J., Ng, L., Needleman, I., Walsh, T., & Li, C. (2018). Oral care
measures for preventing nursing home‐acquired pneumonia. Cochrane Database of
Systematic Reviews, (9).
Longti, L., Zhibing, A., Xuoesong Z., & Luo, J. (2015). Can routine oral care with antiseptics
prevent ventilator- associated pneumonia in patients receiving mechanical ventilation?
An updated meta-analysis from 17 randomized controlled trials. Department of
Science and Research. 8 (2). 1645-1657.

25VENTILATOR-ASSOCIATED PNEUMONIA
Maertens, B., Blot, K., & Blot, S. (2018). Prevention of ventilator-associated and early
postoperative pneumonia through tapered endotracheal tube cuffs: a systematic
review and meta-analysis of randomized controlled trials. Critical care medicine,
46(2), 316-323.
Michaud, G. C., Channick, C. L., Law, A. C., McCannon, J. B., Antkowiak, M., Garrison, G.,
... & DuBrock, H. (2016). Strategies to prevent ventilator-associated pneumonia in
acute care hospitals: 2014 update. Annals of the American Thoracic Society, 13(7),
1160-1169.
Nayak, S. G., Norohna, J. A., & Chakrabarthy, J. (2018). Oral care practices among orally
intubated patients-a systematic review. Manipal Journal of Nursing and Health
Sciences (MJNHS), 4(1), 40-44.
Ory, J., Raybaud, E., Chabanne, R., Cosserant, B., Faure, J. S., Guérin, R., ... & Traore, O.
(2017). Comparative study of 2 oral care protocols in intensive care units. American
journal of infection control, 45(3), 245-250.
Rabbany, M., E, Zaghlol, N., Bhandari, M., & Azarpazhooh, A. (2015). Prophylactic oral
health procedures to prevent hospital-acquired and ventilator-associated pneumonia:
A systematic review. International Journal of Nursing Studies. 52, 452-464. Journal
homepage: www.elsevier.com/ijns.
Rabello, F., Araujo, V. E., & Magalhaes, S. M. A. (2018). Effectiveness of oral chlorhexidine
for the prevention of nosocomial pneumonia and ventilator- associated pneumonia in
intensive care units: Overview of systematic reviews. International Journal of Dental
Hygiene. 16, 441-449.

26VENTILATOR-ASSOCIATED PNEUMONIA
Righy, C., do Brasil, P. E. A., Vallés, J., Bozza, F. A., & Martin-Loeches, I. (2017). Systemic
antibiotics for preventing ventilator-associated pneumonia in comatose patients: a
systematic review and meta-analysis. Annals of intensive care, 7(1), 67.
Sadasivan, P., George, L., & Krishnakumar, K. (2018). Ventilator associated pneumonia-
diagnosis and prevention strategies in critically ill patients: A review. World Journal
of Pharmaceutical Research. 7 (11), 439-449.
Scannapieco, F. A., & Harris, K. W. (2016). Oral health and pneumonia. In A Clinician's
Guide to Systemic Effects of Periodontal Diseases (pp. 81-92). Springer, Berlin,
Heidelberg.
Schreiber, P. W., Sax, H., Wolfensberger, A., Clack, L., & Kuster, S. P. (2018). The
preventable proportion of healthcare-associated infections 2005–2016: Systematic
review and meta-analysis. Infection Control & Hospital Epidemiology, 39(11), 1277-
1295.
Silvestri, L., Weir, W. I., Gregori, D., Taylor, N., Zandstra, D. F., van Saene, J. J., & van
Saene, H. K. (2017). Impact of oral chlorhexidine on bloodstream infection in
critically ill patients: systematic review and meta-analysis of randomized controlled
trials. Journal of cardiothoracic and vascular anesthesia, 31(6), 2236-2244.
Speck, K., Rawat, N., Weiner, N. C., Tujuba, H. G., Farley, D., & Berenholtz, S. (2016). A
systematic approach for developing a ventilator-associated pneumonia prevention
bundle. American journal of infection control, 44(6), 652-656.
Spreadborough, P., Lort, S., Pasquali, S., Popplewell, M., Owen, A., Kreis, I., ... & Vohra, R.
S. (2016). A systematic review and meta-analysis of perioperative oral
decontamination in patients undergoing major elective surgery. Perioperative
Medicine, 5(1), 6

27VENTILATOR-ASSOCIATED PNEUMONIA
Timsit, J. F., Esaied, W., Neuville, M., Bouadma, L., & Mourvillier, B. (2017). Update on
ventilator-associated pneumonia. F1000Research, 6.
Tokmaji, G., Vermeulen, H., Muller, M. C. A., Kwakman, P. H. S., Schultz M. J., & Zaat, S.
A. J. (2015). Silver- coated endotracheal tubes for prevention of ventilator-associated
pneumonia in critically ill patients (Review). Cochrane Database of Systematic
Review, 1- 40.
Vilela, M. C. N., Ferreira. G. Z., Santos, P. S. D. S., & Rezende, P. M. D. (2015). Oral care
and nosocomial pneumonia: a systematic review. Eintein. 13 (2), 290-6.
Villar, C., C., Pannuti, C., M., Nery, D., N., Morillo, C., M., R., Carmona, M., I., C., &
Romito, G. A. (2016). Effectiveness of Tntraoral Chlorhexidine Protocols in the
Prevention of ventilator- Associated Phneumonia: Meta- Analysis and Systematic
Review. Respiratory Care. 61(9), 1245-1259.
Yeganeh, M., Yekta, H., Farmanbar, R., Khalili, M., Khaleghdoost, T. & Roushan, Z. (2019).
Knowledge of evidence-base guidelines in ventilator- assoicated pneumonia
prevention. Journal of Evidence- Based Medicine, 16-21.
Zhang, Z., Hou, Y., Zhang, J., Wang, B, Zhang, J., Yang, A, Li, G., & Tian, J. (2017).
Comparison of the effect of oral care with four different antiseptics to prevent
ventilator- associated pneumonia in adults: protocol for a network meta- analysis.
Systematic reviews, 103(6), 1-5.

28VENTILATOR-ASSOCIATED PNEUMONIA
Appendixes
Appendix A: Proposed Timeframe
Dates 21.03.2019 30.04.2019 14.05.2019 19.05.2019 19.05.2019 22.05.2019 24.05.2019
Tasks Formulate
Project question
(PICO)
Develop
eligibility
criteria
Literature
review
Screening the
literature, assessing
the quality of
studies
Data
Extraction
Synthesize and
interpret the
results
Submit
Project
Report
Comments The PICO
question was
formulated on
time.
The inclusion
and exclusion
criteria was set
Extensive
literature review
was conducted
Detail assessment
of the study was
done to extract the
outcome
Data was
extracted
Result was
interpreted based
on the findings
observed
Final project
report was
submitted

29VENTILATOR-ASSOCIATED PNEUMONIA
Appendix B: Search Strategies in JBI Database of Systematic Review,
MEDLINE Database, Cochrane Database of Systematic Review, and CINAHL
PLUS
1. Prevention of ventilator associated pneumonia, hospital acquired
infection or nosocomial pneumonia or VAP
2. Oral care or mouth hygiene or mouth care or oral health
3. Prevention of ventilator associated pneumonia or effectiveness of
antiseptics
4. Effectiveness of oral hygiene patients with mechanical ventilation
5. Prevention of ventilator associated pneumonia and oral care
6. Prevention of ventilator associated pneumonia and Prevention of
ventilator associated pneumonia or Prevention of ventilator associated
pneumonia and effectiveness of antiseptics
7. Mouth care in intensive care unit and systematic review
8. Prevention of ventilator associated pneumonia and Systematic review
9. Prevention of ventilator associated pneumonia and Systematic review
10.Limited to English language, human, year of publication (published in
last 5 year, such as 2015 to 2019) because it gives more up-to-date
information regarding research problem.

30VENTILATOR-ASSOCIATED PNEUMONIA
Appendix C: List of excluded articles
REFERENCES REASON FOR EXCLUSION
Atashi, V., Yousefi, H., Mahjobipoor, H., Bekhradi,
R., & Yazdannik, A. (2018). Effect of oral care
program on prevention of ventilator-associated
pneumonia in intensive care unit patients: A
randomized controlled trial. Iranian journal of
nursing and midwifery research, 23(6), 486.
It was a randomized control trail.
Balamurugan, E., Kanimoxhi, A., & Kumari, G.
(2012). Effectiveness of chlorhexidine oral
decontamination in reducing the incidence of
ventilator associated pneumonia: a meta-analysis.
British Journal of Medical Practitioners, 5(1), 6-11.
The article was older and fulfilling the inclusion
criteria
Chacko, R., Rajan, A., Lionel, P., Thilagavathi, M.,
Yadav, B., & Premkumar, J. (2017). Oral
decontamination techniques and ventilator-associated
pneumonia. British Journal of Nursing, 26(11), 594-
599.
A double-blind randomised controlled trial was
conducted in this study.
Craven, D. E., Zias, N., & Chroneou, A. (2016).
Managing Ventilator-Associated Pneumonia:
Antibiotic Therapy and Targeted Prevention.
In Respiratory Infections (pp. 141-158). CRC Press.
This study used antibiotic therapy instead of
antiseptic therapy.
Glurich, I., Shimpi, N., Scannapieco, F., Vedre, J., &
Acharya, A. (2019). Interdisciplinary Care Model:
Pneumonia and Oral Health. In Integration of
Medical and Dental Care and Patient Data (pp. 123-
139). Springer, Cham.
The study did not consider ventilator-associated
pneumonia.
Grap, M. J., Munro, C. L., Unoki, T., Hamilton, V.
A., & Ward, K. R. (2012). Ventilator-associated
pneumonia: the potential critical role of emergency
The study was older and did not meet the inclusion
criteria.

31VENTILATOR-ASSOCIATED PNEUMONIA
medicine in prevention. The Journal of emergency
medicine, 42(3), 353-362.
Hurley, J. (2018). Unusually high incidences of
Staphylococcus aureus infection within studies of
ventilator associated pneumonia prevention using
topical antibiotics: benchmarking the evidence
base. Microorganisms, 6(1), 2.
The study focused on antibiotic therapy hence did
not meet the inclusion criteria.
Hurley, J. C. (2018). Paradoxical Acinetobacter-
associated ventilator-associated pneumonia incidence
rates within prevention studies using respiratory tract
applications of topical polymyxin: benchmarking the
evidence base. Journal of Hospital Infection, 100(1),
105-113.
The study deals with Acinetobacter-associated
Ventilator Associated pneumonia.
Iosifidis, E., Pitsava, G., & Roilides, E. (2018).
Ventilator-associated pneumonia in neonates and
children: a systematic analysis of diagnostic methods
and prevention. Future microbiology, 13(12), 1431-
1446.
The study focused on only paediatric ICU patients.
Klarin, B., Adolfsson, A., Torstensson, A., &
Larsson, A. (2018). Can probiotics be an alternative
to chlorhexidine for oral care in the mechanically
ventilated patient? A multicentre, prospective,
randomised controlled open trial. Critical
Care, 22(1), 272.
The study focused on comparison of probiotics as an
alternative to chlorhexidine.
Manger, D., Walshaw, M., Fitzgerald, R., Doughty,
J., Wanyonyi, K. L., White, S., & Gallagher, J. E.
(2017). Evidence summary: the relationship between
oral health and pulmonary disease. British dental
journal, 222(7), 527.
The study focused on oral health and pulmonary
disease.
Nobahar, M., Razavi, M. R., Malek, F., & Ghorbani, The study did not focus on ventilator-associated

32VENTILATOR-ASSOCIATED PNEUMONIA
R. (2016). Effects of hydrogen peroxide mouthwash
on preventing ventilator-associated pneumonia in
patients admitted to the intensive care unit. Brazilian
Journal of Infectious Diseases, 20(5), 444-450.
pneumonia.
Pássaro, L., Harbarth, S., & Landelle, C. (2016).
Prevention of hospital-acquired pneumonia in non-
ventilated adult patients: a narrative
review. Antimicrobial Resistance & Infection
Control, 5(1), 43.
The study focused on non-ventilated patients other
than patients present on mechanical ventilation.
Snyders, O., Khondowe, O., & Bell, J. (2011). Oral
chlorhexidine in the prevention of ventilator-
associated pneumonia in critically ill adults in the
ICU: a systematic review. Southern African Journal
of Critical Care, 27(2), 48-56.
The article was old and did not fulfil the inclusion
criteria.
Vollman, K., Sole, M. L., & Quinn, B. (2016). 4
Endotracheal Tube Care and Oral Care Practices for
Ventilated and Non-ventilated Patients. AACN
Procedure Manual for High Acuity, Progressive, and
Critical Care-E-Book, 32.
The article focused on both ventilated and non-
ventilated patients.

33VENTILATOR ASSOCIATED PNEUMONIA
Appendix D: AMSTAR Critical appraisal form
AMSTAR ITEM El-
Rabbany
et al.,
(2015)
Zhang et
al.,
(2017)
Rabello,
Araujo &
Magalhaes
(2018)
Villar et
al., (2016)
Vilela et
al.,
(2015)
Hua et al.,
(2016)
Tokmaji
et al.,
(2015)
Was any a prior
design provided?
0 0 0 0 0 0 0
Was there duplicate
study selection and
data extraction?
1 1 1 1 0 1 1
Was a
comprehensive
literature search
performed?
1 0 0 0 0 1 1
Was the status of
publication (that is,
grey literature) used
as an inclusion
criterion?
1 0 1 0 0 0 1
Was a list of studies
(included and
excluded)
provided?
1 0 0 1 1 1 1
Were the
characteristic of the
included studies
provided?
1 1 0 1 1 1 1
Was the scientific
quality of the
included studies
assessed and
formulating
conclusions?
1 1 0 1 0 1 1
Was the scientific
quality of the
included studies
used appropriately
in formulated
conclusions?
1 0 1 1 1 0 1
Were the methods
used to combine the
findings of studies
appropriate?
0 1 1 1 1 1 1
Was the likelihood
of publication bias
assessed?
1 1 0 1 0 1 1
Was the conflict of
interest included?
1 0 1 0 0 0 0
Total 9 5 5 7 4 7 9

34VENTILATOR ASSOCIATED PNEUMONIA

35VENTILATOR ASSOCIATED PNEUMONIA
Appendix E: Data Extraction Form
Author
Year
Country
Focus
Search details,
range (database
searched, articles
included)
Quality
Score
Number of studies
Design of included
studies
Intervention/
Comparison
Main
Outcome
measure
El-Rabbany
et al., (2015
200 articles were
included using
goggle scholar
28 Randomized
controlled design was
used. 28 studies were
controlled.
28 trails were
included out of
which 26 were
included in
short-term
studies
conducted in
ICU and 2
were included
in long-term
studies
conducted in
nursing home.
Oral health
care is
considered as
the effective
method in
preventing
ventilator
associated
pneumonia in
both nursing
home and
ICU.
Zhang et
al., (2017)
CNKI, WanFang
database,
PubMed, Web of
Science,
Cochrane
Library,
EMBASE,
SinoMed from
their inception to
March 2016
were the
database
searched.
GRADE
approach was
used to
evaluate the
quality of the
research
evidence.
The studies were
selected using
Cochrane Handbook
for Systematic
Reviews of
Interventions.
Bayesian
methods was
used for both
fixed and
random-effects
multiple
treatment
comparisons
(MTC) for
indirect
comparisons
The outcome
measure is
VAP
morbidity and
the
effectiveness
was not clear
due to no
head-to-head
randomized
controlled
trial.
Rabello,
Araujo &
Magalhaes
(2018)
PubMed, Lilacs,
Centre of
Reviews and
Dissemination
(CRD),
Cochrane
Library and
CINHAL
databases for
relevant articles
published up to
September, 2016
16 quality
articles were
further
included in
the study.
CINHAL database
was used in the study
Systematic
review was
conducted for
comparing two
groups of
patient: patient
with ventilator-
associated and
nosocomial
pneumonia in
cardiothoracic
ICU as
compared to
the patient in
ICU
The result is
effective for
the patient in
cardiothoracic
ICU as
compared to
other patient
Villar et al., The database 2 quality 4 studies were Protocol on It was noticed

36VENTILATOR ASSOCIATED PNEUMONIA
(2016) searched were
MEDLINE,
LILACS and
EMBASE
database and 13
articles were
included.
articles were
included in
the report.
included using
randomized control
design method.
oral
documentation
using test
group
(chlorhexidine)
were compared
from the
standard
protocol using
no-treatment
method or
placebo
method.
that oral care
associated
with
chlorhexidine
is beneficial
in decreasing
VAP
prevalence in
the grownup
(adult)
population if
chlorhexidine
is given 4
times a day or
more 2%
concentrated.
Vilela et
al., (2015)
The database
searched were
PubMed, Scopus
and LILACS
database and 14
articles were
included.
5 quality
articles were
include in the
study
Randomized control
design was used and
12 articles were
included.
0.12% of
Chlorhexidine
is used as an
intervention,
two times a
day. Two
groups were
selected and
one group was
given the
medicine while
the other group
was given
placebo.
Oral hygiene
was
considered as
the effective
method using
0.12% of
chlorhexidine
as compared
to dental
brushing.
Hua et al.,
(2016)
The database
searched were
Cochrane,
CENTRAL,
LILACS,
MEDLINE and
VIP Databases.
18 high-
quality articles
were included
in the study
using GRADE
system
Randomized control
design was used and
38 articles were used.
Two groups
were compared
one were
intervention
group who
received oral
care method
and the other
were control
group with no
treatment
Two
outcomes
were
measured as
primary and
secondary
outcomes
including the
mortality rate
and
consumption
of medicines
Haghighi et
al., (2017)
Boas AND
Mucosal-plaque
score was used
to access the oral
cavity. Clinical
Pulmonary
Infection Score
was used to
detect
pneumonia.
50 articles
were included
in this study.
Randomized control
trail was used and 62
articles were
incorporate in the
study.
Two groups
were compared
one were
intervention
group and
control group.
The incidence
rate of the
intervention
group was
low when
compared to
the control
group.

37VENTILATOR ASSOCIATED PNEUMONIA

38VENTILATOR ASSOCIATED PNEUMONIA
Appendix F: Gantt chart