monia have an attributable mortality of up to 50 % when matched to patients with similar illness severity [ 31 ]. Limiting the number of ventilator days by preventing the fi rst intubation, facilitating early extubation, and preventing re­intubation is the best way to prevent VAP. Standardized endotracheal protocols, including elevation of the head of bed and the use of closed suction systems, have been shown to decrease VAP rates in critical care units. Chlorhexidine oral rinses used in the perioperative period have been shown to reduce nosocomial infection rates, and systemic review has found that oral hygiene with chlorhexidine signifi cantly reduces respiratory infections in ventilated patients [ 33 , 34 ]. Antibiotic administration should not be delayed in the septic patient, though when possible, culture diagnosis through bronchoscopy or bronchial-alveolar lavage should be obtained to guide antibiotic selection and duration. For empiric treatment prior to culture results, a distinction is made between early onset (usually within 4–5 days of admis­sion) and late onset (>5 days of hospitalization). For those patients with early-onset HAP, the important bacteria to cover include Streptococcus pneumoniae , Haemophilus infl uenzae , Staphylococcus aureus , and Gram-negative enteric organisms in intubated patients. Patients with late­onset HAP, Pseudomonas , Acinetobacter , and drug-resistant organisms, including methicillin-resistant Staphylococcus aureus , should have coverage. Local antibiograms are impor­tant to monitor, as specifi c resistance patterns may be unique to individual institutions or vary between units or even within a single unit of mixed patient types within individual facilities.