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Ventilator-associated pneumonia remain frequent and serious diseases since they are associated with considerable crude mortality. Pathophysiology is centered on modifications of regional bacterial flora, especially tracheobronchial tree and oropharyngeal sphere. Bacterial migration from an anatomical area to another seems to be the main explanation of these alterations which are called “transcolonization”. The association of transcolonization and lack of tightness of the endotracheal tube cuff provides a direct pathway for bacteria from the upper to the subglottic airways, eventually leading to ventilator-associated pneumonia.Although modification of bacterial flora has been largely studied, the mechanism which underlays the ability of the implantation, growing and interactions with the local microbiome that leads to the observed transcolonization remains to be more clearly deciphered.The aim of our review is to emphasize the cornerstone importance of the “transcolonization” as a nosological entity playing a central role in ventilator-associated pneumonia.Ventilator-associated pneumonia is a frequent an severe nosocomial infection in ICU.Modification of oral flora leads to tracheobronchial colonization and/or pneumonia.These modifications of oral microbiota follow so-called transcolonization.A better understanding of transcolonization is essential to improve VAP prevention.