Journal of Medical Microbiology (2016), 65, 1378–1384 DOI 10.1099/jmm.0.

000368

Staff education aimed at reducing ventilator-

associated pneumonia
Gurdal Yilmaz,1 Hava Aydin,2 Mustafa Aydin,3 Sedat Saylan,4
Hulya Ulusoy4 and Iftihar Koksal1
1
Correspondence Department of Infectious Diseases and Clinical Microbiology, Karadeniz Technical University
Gurdal Yilmaz Medical Faculty, Trabzon, Turkey
gurdalyilmaz53@hotmail.com 2
Department of Infectious Diseases and Clinical Microbiology, Akçaabat Haçkalı Baba State
Hospital, Trabzon, Turkey
3
Department of Norology, Akçaabat Haçkalı Baba State Hospital, Trabzon, Turkey
4
Department of Anesthesiology and Reanimation, Karadeniz Technical University Medical Faculty,
Trabzon, Turkey

Received 4 July 2016
Accepted 15 October 2016
Mechanical ventilation is a life-saving invasive procedure performed in intensive care units (ICUs)
where critical patients are given advanced support. The purpose of this study was to assess the
effect of personnel training on the incidence of ventilator-associated pneumonia (VAP). The study,
performed prospectively in the ICU, was planned in two periods. In both periods, patient
characteristics were recorded on patient data forms. In the second period, ICU physicians and
assistant health personnel were given regular theoretical and practical training. Twenty-two cases
of VAP developed in the pre-training period, an incidence of 31.2. Nineteen cases of VAP
developed in the post-training period, an incidence of 21.0 (P<0.001). Training reduced
development of VAP by 31.7 %. Crude VAP mortality was 69 % in the first period and 26 % in the
second (P<0.001). Statistically significant risk factors for VAP in both periods were prolonged
hospitalization, increased number of days on mechanical ventilation, and enteral nutrition; risk
factors determined in the first period were re-intubation, central venous catheter use and heart
failure and, in the second period, erythrocyte transfusion >5 units (P<0.05). Prior to training,
compliance with hand washing (before and after procedure), appropriate aseptic endotracheal
aspiration and adequate oral hygiene in particular were very low. An improvement was observed
after training (P<0.001). The training of personnel who will apply infection control procedures for
the prevention of healthcare-associated infections is highly important. Hand hygiene and other
infection control measures must be emphasized in training programmes, and standard procedures
in patient interventions must be revised.

INTRODUCTION antacid use, etc.), presence of tracheotomy, surgical proce-

dures performed, re-intubation and invasive procedures
Ventilator-associated pneumonia (VAP) is a significant hos-
(Albertos et al., 2011; American Thoracic Society & Infec-
pital infection that needs to be prevented because of the
tious Diseases Society of America, 2005). Various strategies
high mortality frequently encountered in the intensive care
have been developed to prevent airway colonization and
unit (ICU) (Albertos et al., 2011). Risk factors for develop-
contaminated secretion aspiration, major mechanisms in
ment of VAP include patient defence mechanism failure,
VAP (American Thoracic Society & Infectious Diseases
immune response suppression, prolonged mechanical ven-
Society of America, 2005; Coffin et al., 2008). In order for
tilator (MV) use, presence of underlying disease (diabetes
standard recommendations regarding infection control to
mellitus, chronic obstructive pulmonary disease, etc.), drugs
be capable of implementation, hospital units and ICU per-
used (steroid, previous antibiotics, H2 receptor blocker and
sonnel in particular need to have available sufficient infor-
mation on the subject. Personnel training in all hospitals
Abbreviations: ARICU, anaesthesia and reanimation intensive care unit;
must therefore primarily target hospital staff including
CVC, central venous catheter; ICU, intensive care unit; MV, mechanical nurses, technicians, physicians, anaesthetists and infection
ventilator; VAP, ventilator-associated pneumonia. control teams.
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The purpose of this study was to assess the effect of person-
nel training on the development of VAP.
METHODS
Study design. The study was performed prospectively at the anaesthe-
sia and reanimation ICU (ARICU). The study was approved by the
Medical Ethical Board of the Medical Faculty (ethical approval no.
2009-50). The ARICU provides tertiary health services and consists of
eight beds for the monitoring of patients exposed to trauma and intoxi-
cation and subjects requiring intensive care after surgery. Personnel
include physicians with primary responsibility, specialist anaesthetists
with appropriate intensive care training, nurses, technicians and ancil-
lary staff. Professional experience of the permanent personnel ranges
from 2 to 11 years. Branch physicians attend for consultation. An infec-
tious disease specialist performs day-to-day monitoring.
The study was intended to assess the effect of training on VAP and was
planned in two periods. In the first 6-month period, patient characteris-
tics were recorded on patient data forms. In the second 6-month period,
ARICU physicians and assistant health personnel were given regular the-
oretical and practical training. During this period, patient characteristics
were again recorded on patient data forms.
Patients hospitalized in the ICU for longer than 48 h were included in
the study, and patients attached to MVs were monitored without inter-
vention. VAP was diagnosed by infectious disease specialist outside the
study team on the basis of CDC criteria (Horan et al., 2008). Changes in
patients’ physical examination findings, temperature, white cell count
and mucus properties were monitored daily. Cultures were taken from
potential foci of infection, including endotracheal aspirate, urine, blood
and others from all patients with fever. Differential diagnosis was per-
formed in terms of foci of infection and non-infection=us causes that
might be responsible for fever, other than pneumonia. Demographic
data, underlying diseases, risk factors for infection, symptoms of infec-
tion, foreign bodies used, diagnoses of infection and treatment adminis-
tered for all patients monitored during both stages were recorded on
patient record forms. Personnel were given no information about VAP
levels in the first period, while in the second period, all personnel were
informed about VAP levels on a monthly basis. VAP rate and ventilator
use levels were calculated using the following formulae: VAP rate=VAP
number/ventilator days1000, and ventilator use rate=ventilator days/
patient days (Horan et al., 2008).
Training. Training was provided for ARICU physicians, nurses and
ancillary health personnel: 15 nurses, 6 technicians, 9 cleaning staff and
20 doctors. Before the training began, knowledge assessment tests con-
sisting of 56 questions were drawn up for the doctor, nurse and techni-
cian group and 40 questions for the ancillary personnel group. These
consisted of true/false/do not know and fill in the box-type questions.
Tests were scored out of 100. The group scheduled for training received
seminars and meetings at which information was provided about the
definition, epidemiology, distribution, aetiology, pathogenesis, risk fac-
tors, costs and treatment of VAP; protection and control measures; our
hospital ICU VAP rates; and comparisons with figures for Turkey and
worldwide. Since colonization and aspiration of oropharyngeal and gas-
tric secretions is an important factor in the pathology of VAP, we partic-
ularly concentrated on the need for a semi-seated position, monitoring
of stomach volume, monitoring of cuff pressure, avoidance of unneces-
sary antibiotic use and the need for stress ulcer prophylaxis. The EATS/
CDC recommendations for the prevention of VAP were adopted as
a guide during training (American Thoracic Society & Infectious Dis-
eases Society of America, 2005). A guideline containing health proce-
dures and pneumonia protection and control measures was distributed
to the entire group. Mixed five-member groups (doctor, nurse, techni-
cian and ancillary personnel) and theoretical and practical training were
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Prevention of ventilator-associated pneumonia
repeated in the presence of patients attached to MVs. The knowledge
assessment test was repeated after training. Training was repeated on an
individual basis for individuals scoring less than 80 % on the knowledge
assessment test. The test was then re-administered.
Our aim in providing training was to develop guideline-appropriate
behaviour, attitudes, beliefs and knowledge among personnel. In line
with that objective, application of the recommendations was encouraged
throughout the training period, regular reminders were issued and feed-
back concerning our findings was provided to increase personnel com-
pliance. In order to observe the effect of training and assess personnel
compliance, a group of VAP precautions to be monitored was deter-
mined. Care was taken in determining the subject matter to be moni-
tored in that it should be soundly based on the literature, aiming at
preventing orogastric colonization and aspiration, which are important
in the pathogenesis of VAP, of direct concern to personnel, easy to apply
and sensitive. The group of measures consisted of hand hygiene before
and after aspiration, the taking of barrier measures, wearing of gloves, a
semi-seated position, aseptic endotracheal procedure appropriate to the
technique used, endotracheal cuff pressure monitoring (>20 cm H2O)
and good oral hygiene (once every shift and whenever necessary). Infec-
tion control procedures were observed at least twice a day before and
after training in order to determine the effect of training by the infection
control team. Unnecessary antibiotic use was evaluated once per day by
the infection control team. Aspiration procedures were observed at least
twice per day during monitoring, and records were kept.
Statistical analysis. Data recorded on Microsoft Excel were trans-
ferred to SPSS software. Normal distribution of data obtained by mea-
surement was analysed using the Kolmogorov–Smirnov test. Normally
distributed data were analysed using the Student’s t-test, and non-nor-
mally distributed data were analysed using Mann–Whitney U test. Data
obtained by measurement were expressed as mean±SD, and data
obtained by counting were expressed as percentages and were analysed
using the chi-square test. Significance was set at P<0.05.
RESULTS
Of the 91 patients treated in the ICU in the first period, 71
were attached to MVs, for a total of 706 ventilator days. MV
use rate was 81 %. Twenty-two diagnoses of VAP were made
in 16 patients, and an incidence of 31.2 per 1000 ventilation
days was determined. In the second period, 84 of the 89
patients treated in the ICU were attached to MVs, for a total
of 906 ventilator days. MV use rate was 78 %. Nineteen diag-
noses of VAP were made in 19 patients, and an incidence of
21.0 per 1000 ventilation days was determined. Training
reduced the occurrence of VAP by 31.7 % (P<0.001). Crude
VAP mortality was 69 % in the first period and 26 % in the
second (P<0.001). Characteristics of the patients monitored
in both periods and a risk factor analysis are shown in Table 1.
Statistically significant risk factors for VAP in both periods
were prolonged hospitalization, increased number of MV
days and enteral nutrition; risk factors determined in the first
period were re-intubation, central venous catheter (CVC) use
and heart failure and, in the second period, erythrocyte trans-
fusion >5 units (P<0.05).
Mean score in the pre-training period was 59.6±6.2, rising
to 92.8±2.9 after training. A statistically significant
improvement in knowledge assessment test score was deter-
mined after training (P<0.001). Prior to training, compli-
ance with hand washing (before and after procedure),
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G. Yilmaz and others

Table 1. Analysis of risk factors for VAP

Risk factors First period Second period

VAP (+) VAP ( ) P VAP (+) VAP ( ) P

(n=16) (n=55) (n=19) (n=65)

Age 54.6±17 48.6±20.5 0.250 49.6±16.8 50.8±22.5 0.834

Gender (male) 10 (62.5 %) 31 (56.3 %) 0.880 10 (52.6 %) 41 (63.7 %) 0.580
APACHE II 18.9±4.1 16.1±5.2 0.050 20.2±4 18.6±4.6 0.192
Days of hospitalization 36.4±28.4 8.4±6.1 0.001 23.1±11 12.1±11.6 <0.001
Ventilator days 29.8±25.2 4.2±4.5 <0.001 20.4±12.0 11.5±8 <0.001
Mortality 11 (68.8 %) 17 (31 %) 0.015 5 (26.3 %) 18 (27.6 %) 0.861
Previous antibiotic use 7 (43.7 %) 13 (23.6 %) 0.129 5 (26.3 %) 16 (24.6 %) 1.000
Re-intubation 4 (25 %) 3 (5.4 %) 0.041 3 (15.7 %) 10 (15.3 %) 1.000
Tracheotomy 3 (18.7 %) 4 (7.2 %) 0.184 1 (5.2 %) 1 (1.5 %) 0.403
Enteral nutrition 15 (93.7 %) 21 (38 %) <0.001 14 (73.7 %) 25 (38.5 %) 0.014
Erythrocyte transfusion 14 (87.5 %) 43 (78.1 %) 0.333 13 (68.4 %) 40 (61.5 %) 0.584
Erythrocyte transfusion >5 9 (56.2 %) 21 (38.1 %) 0.198 10 (52.6 %) 17 (26.1 %) 0.030
Immunosuppression 2 (12.5 %) 7 (12.7 %) 1.000 3 (15.7 %) 10 (15.3 %) 1.000
(steroid use)
CVC 16 (100 %) 35 (63.6 %) 0.003 17 (89.4 %) 43(66.1 %) 0.081
Abdominal surgery 1 (6.2 %) 11 (20 %) 0.274 3 (15.7 %) 14 (21.5 %) 0.750
Thoracic surgery 3 (18.7 %) 7 (12.7 %) 0.683 2 (10.5 %) 3 (4.6 %) 0.315
Trauma 4 (25 %) 20 (36 %) 0.585 8 (40 %) 19 (29.2 %) 0.436
ARDS 1 (6.2 %) 2 (3.6 %) 0.540 1 (5.2 %) 4 (6.1 %) 1.000
COPD 1 (6.2 %) 2 (3.6 %) 0.540 2 (10.5 %) 8 (12.5 %) 1.000
Kidney failure 2 (12.5 %) 11 (20 %) 0.719 4 (21 %) 6 (9.2 %) 0.223
Liver failure 0 (0 %) 4 (7.2 %) 0.567 1 (5.2 %) 4 (6.1 %) 1.000
Heart failure 6 (37.5 %) 4 (7.2 %) 0.006 6 (31.5 %) 8 (12.5 %) 0.075
Respiratory failure 12 (75 %) 32 (58 %) 0.353 13 (68.4 %) 37 (56.9 %) 0.527
Diabetes mellitus 2 (12.5 %) 14 (25.4 %) 0.334 6 (31.55 %) 10 (15 %) 0.180

APACHE, Acute Physiology and Chronic Health Evaluation; COPD, chronic obstructive pulmonary disease; ARDS, acute respiratory distress
syndrome.

appropriate aseptic endotracheal aspiration and adequate 2008). A study from France reported an incidence of VAP of
oral hygiene in particular were very low. An improvement 15, and figures of 5.5 in Germany and 35 in Italy have been
was observed after training, albeit not at the desired level reported (Bouza et al., 2003; Giard et al., 2008; Meyer et al.,
(P<0.001). Glove use, cuff pressure and use of a semi-seated 2009). The INICC has reported an incidence of VAP in devel-
posture, levels of which were not low before training, did oping countries of 18.4 per 1000 ventilator days and an inci-
not increase statistically significantly between the two peri- dence of 21.4 in Turkey (Leblebicioglu et al., 2014; Rosenthal
ods when they were applied after training (P=0.06, P=0.096 et al., 2012) Levels of ventilator use and incidence of VAP in
and P=0.086, respectively). Pre- and post-training values of this study were, respectively, four to five times higher than
parameters monitored to observe personnel compliance and approximately the same as those in developing countries.
with training are shown in Table 2. The decrease in the incidence of VAP despite ventilator use
rates being similar in both periods is significant in revealing
the effect of training and the subjects emphasized in that
DISCUSSION training.
VAP, which may develop as a result of intubation and MV Several studies have investigated VAP development and risk
use, is the most common nosocomial infection in the ICU factors. Age, type of mechanical ventilation, underlying dis-
and significantly increases mortality and prolongs hospitaliza- eases, gastric content aspiration, coma Acute Physiology
tion (Zilberberg & Shorr, 2011). According to National and Chronic Health Evaluation II score, respiratory failure,
Healthcare Safety Network data, median VAP rates in differ- chronic and immunosuppressive conditions, abdominal–
ent ICUs range from 0.7 to 8.3, with values corresponding to thoracic surgery, frequently used therapeutic methods such
the 90th percentile ranging from 4.1 to 16.7 (Horan et al., as previous antibiotic drug use, endotracheal aspiration,
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Table 2. Levels of appropriate personnel procedures
Pre-training (%)
Hand hygiene
Pre-procedure (n=50) 26
Post-procedure (n=50) 30
Glove use (n=50) 86
Aspiration technique (n=50) 22
Semi-seated position (n=100 days) 72
Cuff pressure (n=100) 84
Oral care (n=100 days) 14
OR, odds ratio;CI, confidence interval.
presence of vascular catheter, nasogastric tube, H2 blocker
use, enteral nutrition, tracheotomy, changing ventilator
cycles before 48 h, intensive care hospitalization and length
of invasive procedures have all been considered as potential
risk factors (Agarwal et al., 2006; Albertos et al., 2011;
Carrilho et al., 2007; Erbay et al., 2004; Meric et al., 2005).
This study involved two periods, pre- and post-training,
and risk analyses were performed separately for patients
diagnosed with VAP in both periods. Prolonged hospitaliza-
tion, prolonged MV days and enteral nutrition were identi-
fied as risk factors for VAP in both periods; re-intubation,
CVC use and heart failure, as risk factors in the first period;
and erythrocyte transfusion >5 units as a risk factor in the
second period. The decrease in the incidence of VAP,
although there was no difference between the two groups in
terms of underlying risk factors, reveals the importance of
such training.
VAP prevention measures must commence before the intu-
bation procedure and be maintained until extubation. At
the same time, these measures must be evidence based, easy
to apply and cost-effective. Studies performed in the USA
some 30 years ago showed that nosocomial infections can
be reduced by 30 % with infection control programmes
(Haley et al., 1985). Additionally, the optimal approach to
prevention of VAP is uncertain (Babcock et al., 2004; Zack
et al., 2002). Studies have shown that health worker failure
is associated with increased VAP levels and that VAP pre-
vention measures are either not widely or badly applied
(Ricart et al., 2003; Thoren et al., 1995). One study per-
formed in France and Canada, applying seven strategies for
the prevention of VAP, revealed that compliance with
guidelines was low in both countries (Cook et al., 2000). In
a similar study from Europe, compliance with recommen-
dations was at the 37 % level (Rello et al., 2002). Therefore,
training of all health personnel must be a precondition for
infection control in all ICUs, and particularly units with
limited resources, in order to increase compliance with
these recommendations (Babcock et al., 2004). The results
of studies investigating the effects of training on VAP pre-
vention are successful and instructive. Results from such
studies are summarized in Table 3 (Babcock et al., 2004;
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Prevention of ventilator-associated pneumonia
Post-training (%) P OR CI
74 <0.001 0.20 0.08–0.50
72 <0.001 0.17 0.06–0.43
98 0.06 0.13 0.01–1.09
66 <0.001 0.15 0.05–0.38
96 0.086 0.11 0.003–0.34
96 0.096 0.22 0.06–0.73
58 <0.001 0.12 0.06–0.25
Berenholtz et al., 2011; Danchaivijitr et al., 2005; Kelleghan
et al., 1993; Rosenthal et al., 2006; Salahuddin et al., 2004;
Zack et al., 2002). Incidence of VAP in our study was 31.2
per 1000 ventilator days before training and 21.0 after train-
ing (P<0.001).
Combinations of different models have been used as train-
ing methods in studies investigating the effects of training
on levels of infection. The training methods generally used
include lectures, video presentations, posters, surveys and
practical training sessions (Coopersmith et al., 2004). In
our study, training was provided in the form of detailed
information with visual presentations (definition of VAP,
epidemiology, distribution, pathogenesis, risk factors, costs,
treatment, protection and control measures). Levels of
knowledge were assessed using tests. Guidelines were given
to all personnel. Practical sessions were held at the bedside.
Guideline compliance levels were reported to the staff on a
regular basis. Good post-training results were achieved
from knowledge assessment tests performed to evaluate the
quality and effect of training.
Aspiration into the lower respiratory tract of pathogenic
bacteria colonizing the respiratory and digestive tracts is the
most important factor in the pathogenesis of VAP (Ricart
et al., 2003). Therefore, in determining clinical strategies to
prevent VAP, there has been considerable emphasis on sim-
ple measures (hand washing, appropriate removal of respi-
ratory secretions, glove use, etc.) that can prevent this
colonization and aspiration (Albertos et al., 2011; Ricart
et al., 2003). Since hand hygiene represents the basis of
infection control, studies have emphasized the importance
and effects of compliance with hand hygiene (Albertos et al.,
2011; Boyce et al., 2002). An educational study showing the
effectiveness of specific control procedures (respiratory tract
care and application of aseptic procedures) reported that
hand-washing levels increased from 5 % to 63 % and that
the incidence of VAP decreased from 113 per 1000 ventila-
tor days to 40 (Berg et al., 1995). One other study applied a
2-year multifaceted education programme for the preven-
tion of VAP and observed compliance with training of the
personnel engaged in patient care. The compliance markers
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G. Yilmaz and others

Table 3. Studies showing the effect of training on VAP rates

Place–year Reference Infection RR (95 CI%)

P value
Pre-training Post-training

USA–1993 Kelleghan et al. (1993) 7 cases/100 patients 3 cases/100 patients 0.43 (NR) P<0.05
USA–2002 Zack et al. (2002) 12.6/1000 ventilator days 5.7/1000 ventilator days 0.45 (NR) P<0.001
USA–2004 Babcock et al. (2004) 8.75/1000 ventilator days 4.74/1000 ventilator days 0.54 (NR) P<0.001
Argentina–2004 Salahuddin et al. (2004) 13.2/1000 ventilator days 6.5/1000 ventilator days 0.52 (0.30–0.91) P=0.02
Thailand–2005 Danchaivijitr et al. (2005) 40.5 % 24 % 0.59 (NR) P<0.001
Argentina–2006 Rosenthal et al. (2006) 51.3/1000 ventilator days 35.5/1000 ventilator days 0.69 (0.49–0.98) P=0.003
USA–2011 Berenholtz et al. (2011) 5.5/1000 ventilator days 0/1000 ventilator days 0.51 (0.41–0.64) P<0.001

hand hygiene, glove use, elevation of bed head, endotracheal
tube cuff pressure level, orogastric tube use, gastric volume
monitoring, oral hygiene and avoidance of unnecessary tra-
cheal aspiration procedures were monitored, and compli-
ance with recommendations was shown to affect the
incidence of VAP (Bouadma et al., 2010).
‘Care bundle’ concepts have recently been developed from
the expectation that better and more effective results could
be obtained from the use in groups of evidence-based ideas
in the prevention of infection. The best-known and most
widely used ‘ventilator care bundle’ was developed by the
Institute of Healthcare Improvement (Berwick et al., 2006).
That bundle consisted of raising the bed head to 30–45  ,
daily sedation vacation and assessment for extubation, and
prophylaxis for peptic ulcer and deep vein thrombosis. The
Institute of Healthcare Improvement also recommended
the addition to this bundle of the components personnel
training, compliance with hand hygiene, oral care with
chlorhexidine, weekly changing of ventilator tubes, aspira-
tion of subglottic secretions and constant cuff pressure
monitoring.
One study performed in the USA that observed changes
in the incidence of VAP according to compliance with
five recommendations, including shortening the period of
MV use together with a ventilator care bundle, reported a
pre-education level of compliance with procedures of
32 %, rising to 75 % after 18 months and 84 % after 30
months. Pre-intervention incidence of VAP was 5.5,
decreasing to 3.4 after 18 months and 2.4 after 30 months
(Berenholtz et al., 2011).
On the basis of our observations in the pre-training period
in the ICU, we determined personnel compliance with stan-
dard infection prevention and measures to prevent aspira-
tion of infected secretions into the respiratory tract as a care
bundle. That bundle involved hand washing before and
after procedures, indication-appropriate glove use, aseptic
endotracheal aspiration, correct bed head position, cuff
pressure monitoring and oral hygiene procedures of suffi-
cient quality and number.
Compliance with hand hygiene before patient intervention
and aspiration procedures was very low (26 %), and hand
hygiene compliance after the same procedures was also low
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(30 %). Patient care and aspiration procedures are generally
performed by nurses and health technicians, and no differ-
ence was observed in hand hygiene levels between the two
groups. In addition to this low level of hand hygiene, per-
sonnel wore the same gloves before every procedure and
were able to continue with procedures even after if they
had touched contaminated secretions with the same gloves.
Appropriate instruction was provided during training, with
particular attention paid to hand hygiene indications. Post-
training, pre-procedure hand hygiene compliance level was
64 % and post-procedure hand hygiene compliance was
72 %. Pre-procedure hand hygiene compliance increased by
80 % with training, and post-procedure compliance
increased by 83 %. While this finding shows the effective-
ness of the training, it is insufficient for the purposes of our
study, which was intended to prevent hospital infections
and VAP. Frequent provision and repetition of training ses-
sions, personnel compliance with hand hygiene and feed-
back about incidences of infection are highly important.
Neglect or improperly understood procedures were
observed in the opening of sterile aspiration probes, aspira-
tion being performed once and for 15 s at most, the probe
being washed and the interior of the mouth being aspirated
following endotracheal aspiration, and the probe being
washed and disposed of following the procedure. The level
of correct application of aspiration was 22 % before train-
ing, rising to 66 % after training. Training improved appli-
cation by 85 %. We believe that regular and controlled
training needs to be provided in order to increase compli-
ance still further and change previous incorrect practices.
Control of hospital infections is possible only if appropriate
infection measures are taken, with infections being moni-
tored using standard techniques and problems being identi-
fied. A 31.7 % decrease in the incidence of VAP was
observed following training provided on the basis of the
problems identified in this study. The successful results
from this and education studies show that the training of
ICU personnel who will apply infection control measures is
very important to the prevention of VAP and other hospital
infections. Hand hygiene, the basic component of infection
control, must be emphasized in training provided, and stan-
dard procedures in patient interventions must be reviewed.
Journal of Medical Microbiology 65

In conclusion, guidelines must be adopted in the prevention
of hospital-acquired infections, and every country, hospital
and ICU must take infection control measures on the basis
of its own local problems. Personnel awareness of their
duties must be increased, training must be regarded as
indispensable for the prevention of infections, and prevent-
able risk factors must be minimized.
ACKNOWLEDGEMENT
There is no conflict of interest or financial support in this study.
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