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1. Vincent JL, Rello J, Marshall J, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA2009;302(21):2323-2329.

2. Dudeck MA, Weiner LM, Allen-Bridson K, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module.AJIC 2013;41(12):

1148-1166.

3. Kollef MH, Morrow LE, Niederman MS, et al. Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest 2006;129(5):1210-1218.

4. Rello J, Ollendorf DA, Oster G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122(6):2115-2121.

5. Pneumatikos IA, Dragoumanis CK, Bouros DE. Ventilator-associated pneumonia or endotracheal tube-associated pneumonia? An approach to the pathogenesis and preventive strategies emphasizing the importance of endotracheal tube. Anesthesiology 2009;110(3):673-680.

6. Craven DE, Steger KA. Epidemiology of nosocomial pneumonia: New perspectives on an old disease. Chest 1995;108(2 SUPPL):1S-16S.

7. El-Solh AA, Pietrantoni C, Bhat A, et al. Colonization of dental plaques: A reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest 2004;126(5):1575-1582.

8. , , , .

. 2008;23(2):97-103.

9. Sumi Y, Miura H, Michiwaki Y, et al. Colonization of dental plaque by respiratory pathogens in dependent elderly. Arch Gerontol Geriatr. 2007;44(2):119-124.

10. . .

2017;22(11):52-55.

11. Park DR. The microbiology of ventilator-associated pneumonia. Respir Care2005;50(6): 742-763.

12. 2017 . 3

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(27)

22 . 2017;67(2):70-76. 14. , , , . . 2017;32(4):1334-1339. 15. , , , . . 2011;31(2):34-41.

16. Yamasaki K, Kawanami T, Yatera K, et al. Significance of Anaerobes and Oral Bacteria in Community-Acquired Pneumonia. PLoS ONE 2013;8(5).

17. . ICU

ICU . https://janis.mhlw.go.jp/section/icu.html.2018.12.23 .

18. Lizan-Garcia M, Peyro R, Cortina M,et al. Nosocomial infection surveillance in a surgical intensive care unit in Spain, 1996-2000: a time-trend analysis. Infect Control Hosp Epidemiol. 2006;27(1):54-59.

19. Institute for Healthcare Improvement. Evidence-Based Care Bundles. http://www.ihi.org/Topics/Bundles/Pages/default.aspx.2018.12.23 .

20. Resar R, Pronovost P, Haraden C, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31(5):243-248.

21. Gastmeier P, Geffers C. Prevention of ventilator-associated pneumonia: analysis of studies published since 2004. J Hosp Infect 2007;67(1):1-8.

22. Rello J, Lode H, Cornaglia G,et al. A European care bundle for prevention of ventilator-associated pneumonia. Intensive Care Med 2010;36(5):773-780.

23. Álvarez Lerma F, Sánchez García M, Lorente L, et al. Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish "Zero-VAP" bundle. Med Intensiva. 2014;38(4):226-236.

24. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol.2014;35(8):915-936.

25. . . ICU

CCU 2009;33:749-756.

(28)

23

patients: A systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia. Crit Care Med 2013;41(2):646-655.

27. Pobo A, Lisboa T, Rodriguez A, et al. A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest 2009;136(2):433-439.

28. Kishimoto H, Urade M. Assess dental plaque and suction-extricated bacteria adequately. Chest 2010;137(2):500. 29. . ! . 2013;22:242. 30. , . 2000 2005 . 2005(12);37-44. 31. , . . 2015;30(2):127-134.

32. Fourrier F, Dubois D, Pronnier P, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: A double-blind placebo-controlled multicenter study. Crit Care Med 2005;33(8):1728-1735.

33. Klompas M, Speck K, Howell MD, et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: Systematic review and meta-analysis. JAMA Intern Med 2014;174(5):751-761.

34. Mori H, Hirasawa H, Oda S, et al. Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med 2006;32(2):230-236.

35. Seguin P, Laviolle B, Dahyot-Fizelier C, et al. Effect of Oropharyngeal povidone-iodine preventive oral care on ventilator-associated pneumonia in severely brain-injured or cerebral hemorrhage patients: A multicenter, randomized controlled trial. Crit Care Med 2014;42(1):1-8.

36. , . . ICU CCU 2009;33(10):741-747. 37. , , , , , . . 2009;35(3):426-431. 38. , , , , , . . 2000;7(4):387-388. 39. , , , , , .

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24 . 2003;29:55-58. 40. , . . 2018;7(1):1-11. 41. , . . 2008;45(2):196-201.

42. Hua F, Xie H, Worthington HV, et al. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev 2016;10.

43. Ikeda M, Miki T, Atsumi M, et al. Effective elimination of contaminants after oral care in elderly institutionalized individuals. Geriatr Nurs 2014;35(4):295-299.

44. , , . . 2016;12(3):49-54. 45. , , , . . 2016;11(1):87-89. 46. , . ICU . 2011;18(1):16-19. 47. , , . . 2015;25(2):209-212. 48. , , , . . 2012;27(2):87-96.

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1. Kollef MH, Morrow LE, Niederman MS, et al. Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest 2006;129(5):1210-1218.

2. DeRiso Ii AJ, Ladowski JS, Dillon TA, et al. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest 1996;109(6):1556-1561.

3. Koeman M, Van Der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006;173(12):1348-1355. 4. , . . 2015;30(2):127-134. 5. , , . VAP . 2008;28:27-32. 6. , , , . . ICU CCU 2010;34(6):481-486. 7. , , . VAP . 2010;36(3):292-297. 8. . ! VAP . 2010;8(7):633-640.

9. Binkley C, Furr LA, Carrico R, et al. Survey of oral care practices in US intensive care units. Am J Infect Control 2004;32(3):161-169.

10. Rello J, Koulenti D, Blot S, et al. Oral care practices in intensive care units: A survey of 59 European ICUs. Intensive Care Med 2007;33(6):1066-1070.

11. The American Association of Critical-Care Nurses (AACN)Oral Care Practice Ale:Oral Care for Patients at Risk for Ventilator-Associated Pneumonia. AACN web site.

https://www.aacn.org/docs/EventPlanning/WB0011/oral-care-patients-at-risk-vap-r44spvmp.pdf.2018.12.23 .

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review of the nursing literature. Intensive Crit Care Nurs 2013;29(5):266-274.

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2009;26:234-235.

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, . 2003;20:116-119.

15. Feider LL, Mitchell P, Bridges E. Oral care practices for orally intubated critically ill adults. Am J Crit Care 2010;19(2):175-183.

16. Grap MJ, Munro CL, Ashtiani B, et al. Oral care interventions in critical care: frequency and documentation. Am J Crit Care 2003;12(2):113-118 discussion 119.

17. , , , . A ICU CCU

. 2017;14(2):35-42.

18. Ames NJ. Evidence to support tooth brushing in critically ill patients. Am J Crit Care 2011;20(3):242-250.

19. , . . 2008 25:28-35.

20. Chan EY, Ruest A, Meade MO, et al. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review and meta-analysis. BMJ 2007;334(7599):889-893.

21. , , , .

. ICU CCU 2012 36:53-57.

22. Alexiou VG, Ierodiakonou V, Dimopoulos G, et al. Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. J Crit Care 2009;24(4):515-522.

23. Muscedere J, Rewa O, McKechnie K, et al. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis. Crit Care Med 2011;39(8):1985-1991.

24 Frost SA, Azeem A, Alexandrou E, et al. Subglottic secretion drainage for preventing ventilator associated pneumonia: a meta-analysis. Aust Crit Care 2013;26(4):180-188.

25 Rello, J,Sonora, R,Jubert, P, et al. Pneumonia in intubated patients: role of respiratory airway care. Am J Respir Crit Care Med 1996;154(1):111-115.

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1. O'Keefe-McCarthy S, Santiago C, Lau G. Ventilator-associated pneumonia bundled strategies: An evidence-based practice. Worldviews Evid Based Nurs 2008;5(4):193-204.

2. Klompas M, Speck K, Howell MD, et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: Systematic review and meta-analysis. JAMA Internal Med 2014;174(5):751-761.

3. Price R, MacLennan G, Glen J. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: Systematic review and network meta-analysis. BMJ 2014;348.

4. , . 2015;30(2):127-134. 5. , , . . 2015;11(3):25-33. 6. , , . . 2012;11(2):55-61.

7. Takeyasu Y, Yamane GY, Tonogi M, et al. Ventilator-associated pneumonia risk decreased by use of oral moisture gel in oral health care. Bull Tokyo Dent Coll 2014;55(2):95-102.

8. Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53(RR-3):1-36.

9. Ikeda M, Miki T, Atsumi M, et al. Effective elimination of contaminants after oral care in elderly institutionalized individuals. Geriatric Nursing 2014;35(4):295-299.

10. Meinberg MC, Cheade Mde F, Miranda AL,et al. The use of 2% chlorhexidine gel and toothbrushing for oral hygiene of patients receiving mechanical ventilation: Effects on ventilator-associated pneumonia. Rev Bras Ter Intensiva 2012;24(4):369-374.

11. Seguin P, Laviolle B, Dahyot-Fizelier C, et al. Effect of Oropharyngeal povidone-iodine preventive oral care on ventilator-associated pneumonia in severely brain-injured or cerebral hemorrhage patients: A multicenter, randomized controlled trial. Crit Care Med 2014;42(1):1-8. 12. Hua F, Xie H, Worthington HV, et al. Oral hygiene care for critically ill patients to prevent

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