Sir: I appreciate the comments by Wise and Cole with regard to our article [1] evaluating oral care practices in intensive care units. The question of whether better cleaning of the oral cavity may help to reduce nosocomial infections is indeed intriguing; however, this is expert opinion. It remains unclear whether small brushes, normal brushes, or electrical brushes are equivalent. A randomized clinical trial is ongoing in our department to clarify this issue.

Their observations also reinforce the variability of practices in different ICUs, explained in part by the different cultures of critical care in different European countries, which is well reflected in the participants at the European Society of Intensive Care Medicine (ESICM) congress. We believe this to be an opportunity to develop a consensus document to be implemented as an European guideline. The multidisciplinary approach used for the development of care bundles on hospital-acquired pneumonia developed by a panel of experts [2] is a good model to follow. Indeed, oral care is part of the recommended care bundles for prevention of ventilator-associated pneumonia (VAP), and is recommended by this panel. Once confirmed, however, additional efforts will be necessary to get these recommendations implemented, as recently demonstrated in a study which evaluated the knowledge of ICU nurses about guidelines for the prevention of VAP [3]. Previous reports also pointed out that simply publishing guidelines is insufficient to achieve a high rate of compliance [4, 5]. We believe that here. as well, the ESICM can play a pivotal role.