Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units

INTRODUCTION

Given the high morbidity and mortality attributable to ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, prevention plays a key role in the management of patients undergoing mechanical ventilation. One of the candidate preventive interventions is the selective decontamination of the digestive or respiratory tract (SDRD) by topical antiseptic or antimicrobial agents. We performed a meta-analysis to investigate the effect of topical digestive or respiratory tract decontamination with antiseptics or antibiotics in the prevention of VAP, of mortality and of all ICU-acquired infections in mechanically ventilated ICU patients.

METHODS

A meta-analysis of randomised controlled trials was performed. The U.S. National Library of Medicine's MEDLINE database, Embase, and Cochrane Library computerized bibliographic databases, and reference lists of selected studies were used. Selection criteria for inclusion were: randomised controlled trials (RCTs); primary studies; examining the reduction of VAP and/or mortality and/or all ICU-acquired infections in ICU patients by prophylactic use of one or more of following topical treatments: 1) oropharyngeal decontamination using antiseptics or antibiotics, 2) gastrointestinal tract decontamination using antibiotics, 3) oropharyngeal plus gastrointestinal tract decontamination using antibiotics and 4) respiratory tract decontamination using antibiotics; reported enough data to estimate the odds ratio (OR) or risk ratio (RR) and their variance; English language; published through June 2010.

RESULTS

A total of 28 articles met all inclusion criteria and were included in the meta-analysis. The overall estimate of efficacy of topical SDRD in the prevention of VAP was 27% (95% CI of efficacy = 16% to 37%) for antiseptics and 36% (95% CI of efficacy = 18% to 50%) for antibiotics, whereas in none of the meta-analyses conducted on mortality was a significant effect found. The effect of topical SDRD in the prevention of all ICU-acquired infections was statistically significant (efficacy = 29%; 95% CI of efficacy = 14% to 41%) for antibiotics whereas the use of antiseptics did not show a significant beneficial effect.

CONCLUSIONS

Topical SDRD using antiseptics or antimicrobial agents is effective in reducing the frequency of VAP in ICU. Unlike antiseptics, the use of topical antibiotics seems to be effective also in preventing all ICU-acquired infections, while the effectiveness on mortality of these two approaches needs to be investigated in further research.

Molecular analysis of microbial communities in endotracheal tube biofilms

Background

Ventilator-associated pneumonia is the most prevalent acquired infection of patients on intensive care units and is associated with considerable morbidity and mortality. Evidence suggests that an improved understanding of the composition of the biofilm communities that form on endotracheal tubes may result in the development of improved preventative strategies for ventilator-associated pneumonia.

Methodology/Principal Findings

The aim of this study was to characterise microbial biofilms on the inner luminal surface of extubated endotracheal tubes from ICU patients using PCR and molecular profiling. Twenty-four endotracheal tubes were obtained from twenty mechanically ventilated patients. Denaturing gradient gel electrophoresis (DGGE) profiling of 16S rRNA gene amplicons was used to assess the diversity of the bacterial population, together with species specific PCR of key marker oral microorganisms and a quantitative assessment of culturable aerobic bacteria. Analysis of culturable aerobic bacteria revealed a range of colonisation from no growth to 2.1×10⁸ colony forming units (cfu)/cm² of endotracheal tube (mean 1.4×10⁷ cfu/cm²). PCR targeting of specific bacterial species detected the oral bacteria Streptococcus mutans (n = 5) and Porphyromonas gingivalis (n = 5). DGGE profiling of the endotracheal biofilms revealed complex banding patterns containing between 3 and 22 (mean 6) bands per tube, thus demonstrating the marked complexity of the constituent biofilms. Significant inter-patient diversity was evident. The number of DGGE bands detected was not related to total viable microbial counts or the duration of intubation.

Conclusions/Significance

Molecular profiling using DGGE demonstrated considerable biofilm compositional complexity and inter-patient diversity and provides a rapid method for the further study of biofilm composition in longitudinal and interventional studies. The presence of oral microorganisms in endotracheal tube biofilms suggests that these may be important in biofilm development and may provide a therapeutic target for the prevention of ventilator-associated pneumonia.

Strategies in the prevention of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) remains a significant problem in the hospital setting, with very high morbidity, mortality, and cost. We performed an evidence-based review of the literature focusing on clinically relevant pharmacological and nonpharmacological interventions to prevent VAP. Owing to the importance of this condition the implementation of preventive measures is paramount in the care of mechanically ventilated patients. There is evidence that these measures decrease the incidence of VAP and improve outcomes in the intensive care unit. A multidisciplinary approach, continued education, and ventilator protocols ensure the implementation of these measures. Future research will continue to investigate cost/benefit relationships, antibiotic resistance, as well as newer technologies to prevent contamination and aspiration in mechanically ventilated patients.

Infection prevention in the intensive care unit: review of the recent literature on the management of invasive devices

Over the last 5 y, clinical trials investigating products, procedures, and treatments aimed at preventing infections in the intensive care unit have been described. The findings of these studies appear to confirm the effectiveness of certain preventive procedures. With regard to ventilator-associated pneumonia, the efficacies of decontamination of the oral cavity, continuous suction of subglottic secretions, positioning of the patient, selective decontamination of the digestive tract, and (for higher-risk patients) endotracheal tubes coated with silver, have been demonstrated. Medicated catheters and chlorhexidine-based dressings have been found useful for catheter-related bloodstream infections, and medical catheters have also been shown to be efficacious against urinary tract infections. All these procedures can be incorporated into departmental protocols for the prevention of nosocomial infections in the intensive care unit.

Diagnosis, management and prevention of ventilator-associated pneumonia: an update

Ventilator-associated pneumonia (VAP) affects 10-20% of mechanically ventilated patients and is associated with increased morbidity and mortality and high costs. Early diagnosis is crucial for rapid appropriate antimicrobial therapy to be instituted, but debate remains as to the optimal diagnostic strategy. Noninvasive clinical-based diagnosis is rapid but may not be as accurate as invasive techniques. Increased use of biomarkers and advances in genomics and proteomics may help speed up diagnosis. Management of VAP relies principally on appropriate antimicrobial therapy, which should be selected according to individual patient factors, such as previous antibacterial therapy and length of hospitalization or mechanical ventilation, and local infection and resistance patterns. In addition, once bacterial culture and sensitivity results are available, broad-spectrum therapy should be de-escalated to provide a more specific, narrower-spectrum cover. Optimum duration of antibacterial therapy is difficult to define and should be tailored to clinical response. Biomarker levels may be useful to monitor response to therapy. With the high morbidity and mortality, prevention of VAP is important and several strategies have been shown to reduce the rates of VAP in mechanically ventilated patients, including using noninvasive ventilation where possible, and semi-recumbent positioning. Other potentially beneficial preventive techniques include subglottal suctioning, oral decontamination strategies and antimicrobial-coated endotracheal tubes, although further study is needed to confirm the cost effectiveness of these strategies.

Bladder pressure measurements are an independent predictor of urinary tract infection in trauma patients

PURPOSE

To determine the risk factors for urinary tract infections (UTIs) specific to trauma patients in order to assist in the development of infection control protocols.

METHODS

Data were collected prospectively from January 2003 until December 2005 by an epidemiology nurse and combined with registry data from our Level 1 trauma center. The trauma patients admitted to the Surgery and Trauma Intensive Care Unit (STICU)(n = 938) who did and did not have UTIs were compared for demographics, Injury Severity Score (ISS), and epidemiologic data, including use of Foley catheters and bladder pressure measurements (BPMs). An open system was used for the measurements in which the catheter was disconnected from the bag to instill 50 mL of saline into the bladder, and an 18-gauge needle was inserted into the catheter to measure the pressure.

RESULTS

A total of 50 patients had no Foley catheter or UTIs. Among the 836 patients with catheters but no BPMs, there were 36 UTIs (4.31%), whereas the 52 patients with catheters and BPMs had 12 UTIs (23.08%)(p < 0.0001). Patients with UTIs were more severely injured older females (mean age 40.1 ± 18.6 years with no UTI vs. 48.5 ± 20.8 with UTIs; p = 0.0083; percent female 26.4 no UTI vs. 45.8 UTI; p = 0.007; ISS 19.3 ± 11.3 no UTI vs. 26.2 ± 11.6; p < 0.0001). Using logistic regression, BPM was an independent predictor of UTI, with infection being seven times more likely in the patients having the measurements (odds ratio [OR] 6.99; 95% confidence-interval [CI] 3.087-15.827). Along with age (OR 1.039; CI 1.024-1.054) and ISS (OR 1.081; CI 1.056-1.106), having BPMs was an independent predictor of death (OR 2.475; CI 1.191-6.328).

CONCLUSION

This is the first study that demonstrates a greater risk of UTI with BPM using the open technique independent of patient gender or degree of injury. Given these findings and a previous trial demonstrating no difference in UTI rates with a closed circuit for BPM, our institution has incorporated a closed circuit technique into its infection control protocol.

Dentistry and internal medicine: from the focal infection theory to the periodontal medicine concept

During past decades the relationship between dentistry and internal medicine and especially the concept of the so-called focal infection theory have long been a matter of debate. The pathogenesis of focal diseases has been classically attributed to dental pulp pathologies and periapical infections. Nonetheless, in recent years, their role is being dismissed while increasing interest is being devoted to the possible associations between periodontal infection and systemic diseases. In fact, periodontal pathogens and their products, as well as inflammatory mediators produced in periodontal tissues, might enter the bloodstream, causing systemic effects and/or contributing to systemic diseases. On the basis of this mechanism, chronic periodontitis has been suggested as a risk factor for cardiovascular diseases associated with atherosclerosis, bacterial endocarditis, diabetes mellitus, respiratory disease, preterm delivery, rheumatoid arthritis, and, recently, osteoporosis, pancreatic cancer, metabolic syndrome, renal diseases and neurodegenerative diseases such as Alzheimer's disease. Various hypotheses, including common susceptibility, systemic inflammation, direct bacterial infection and cross-reactivity, or molecular mimicry, between bacterial antigens and self-antigens, have been postulated to explain these relationships. In this scenario, the association of periodontal disease with systemic diseases has set the stage for introducing the concept of periodontal medicine. This narrative review summarizes the evolution of focal infection theory up to the current pathophysiology of periodontal disease, and presents an update on the relationships between chronic periodontitis and systemic diseases.

The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: review and recommendations

Aspiration pneumonia is a leading cause of illness and death in persons who reside in long-term-care facilities and, combined with the lack of proper oral health care and services, the risk of aspiration pneumonia rises. The purpose of this article is to review recent literature on oral hygiene and oral care in long-term-care facilities and report new findings regarding associated risks for aspiration pneumonia, as well as research on oral care and health outcomes. The PubMed MeSH database was utilized to direct a specific search by entering terms "aspiration pneumonia" and "oral hygiene" from 1970 to 2009, which yielded 34 articles. The Ovid and Google Scholar databases were utilized as well and provided no additional references for the two terms. A manual search of references from other articles, including three systematic reviews published over the past decade, provided additional information regarding oral microorganisms and respiratory pathogens, as well as investigations of oral care. Finally, a brief but comprehensive introductory review was organized regarding oral microorganisms, biofilm, periodontal disease, and pneumonia to establish a framework for discussion. Overall, studies suggest (1) an association between poor oral hygiene and respiratory pathogens, (2) a decrease in the incidence of respiratory complications when patients are provided chemical or mechanical interventions for improved oral care, (3) the complex nature of periodontal disease and aspiration pneumonia make direct connections between the two challenging, and (4) additional studies are warranted to determine adequate oral hygiene protocols for nursing home patients to further reduce the incidence of aspiration pneumonia.

The impact of oral health and 0.2% chlorhexidine oral gel on the prevalence of nosocomial infections in surgical intensive-care patients: a randomized placebo-controlled study

OBJECTIVES

To evaluate the impact of oral health on the evolution of nosocomial infections and to document the effects of oral antiseptic decontamination on oral health and on the rate of nosocomial infections in patients in a surgical intensive-care unit (ICU).

DESIGN

A prospective, randomized, double-blind, placebo-controlled clinical trial.

SETTING

Surgical ICU in University Hospital Dubrava.

PATIENTS

The study included 60 nonedentulous patients consecutively admitted to the surgical ICU and requiring a minimum stay of three days.

MAIN OUTCOME MEASURES

After randomization, the treatment group underwent antiseptic decontamination of dental plaque and the oral mucosa with chlorhexidine gel. The control group was treated with placebo gel. Dental status was assessed using a caries-absent-occluded (CAO) score, and the amount of plaque was assessed using a semi-quantitative score. Samples of dental plaque, oral mucosa and nasal and tracheal aspirates were collected for bacterial culture, and nosocomial infections were assessed.

RESULTS

The plaque score significantly increased in the control group and decreased in the treated patients. Patients who developed a nosocomial infection had higher plaque scores on admission and during their ICU stay. The control group showed increased colonization by aerobic pathogens throughout their ICU stay and developed nosocomial infections (26.7%) significantly more often than the treated patients (6.7%); the control group also stayed longer in the ICU (5.1 +/- 1.6 vs. 6.8 +/- 3.5 days, P = 0.019). Furthermore, a trend in reduction of mortality was noted in the treated group (3.3% vs. 10%).

CONCLUSIONS

Among surgical ICU patients, poor oral health had a significant positive correlation with bacterial colonization and the evolution of nosocomial infections. Oral decontamination with chlorhexidine significantly decreased oropharyngeal colonization, the incidence of nosocomial infections, length of ICU stay, and mortality in these patients.

[Oral hygiene with chlorhexidine on the prevention of ventilator-associated pneumonia in intubated patients: a systematic review of randomized clinical trials]

BACKGROUND AND OBJECTIVE

Mechanical ventilation is used in about one third of patients in intensive cares units (ICU). Ventilator Associated-Pneumonia (VAP) is a frequent infectious complication, affecting approximately 8 to 28% patients. Strategies to prevent the development of VAP are key factors in the management of ICU patients. There have been proposed several strategies to prevent VAP. One of these is oral hygiene with clorhexidine. We evaluated the effect of chlorhexidine on the prevention of VAP.

PATIENTS AND METHODS

We conducted a systematic review of controlled clinical trials evaluating the effect of oral hygiene on VAP prevention. A PubMed search was performed using the following keywords: "oral care OR oral hygiene OR chlorhexidine AND ventilator-associated pneumonia". An independent reviewer evaluated the studies according to the inclusion criteria and extracted the data.

RESULTS

A total of 120 articles were found, and 10 of them met the inclusion criteria. A lack of uniformity was appreciated in the application of chlorhexidine. There was a reduction in the risk of VAP in the chlorhexidine group versus control (OR: 0,56, 95% CI: 0,44-0,73). However, neither a reduction in mortality, nor a length of MV nor an ICU length of stay were seen.

CONCLUSIONS

Oral hygiene with chlorhexidine in combination with other strategies for VAP prevention should be included in the patient's ICU care.

Nosocomial pneumonia: importance of the oral environment

Nosocomial pneumonia, especially ventilator-associated pneumonia, is a common infection in ICUs. The main etiologic factors involve colonizing and opportunistic bacteria from the oral cavity. Oral hygiene measures, including the use of oral antiseptic agents, such as chlorhexidine, have proven useful in reducing its incidence. The objective of this article was to review the literature on the importance of the oral environment in the development of nosocomial pneumonia.

Oral care practices for orally intubated critically ill adults

BACKGROUND

Ventilator-associated pneumonia is a major threat to patients receiving mechanical ventilation in hospitals. Oral care is a nursing intervention that may help prevent ventilator-associated pneumonia.

OBJECTIVES

To describe oral care practices performed by critical care nurses for orally intubated critically ill patients and compare these practices with recommendations for oral care in the 2005 AACN Procedure Manual for Critical Care and the guidelines from the Centers for Disease Control and Prevention.

METHODS

A descriptive, cross-sectional design with a 31-item Web-based survey was used to describe oral care practices reported by 347 randomly selected members of the American Association of Critical-Care Nurses.

RESULTS

Oral care was performed every 2 (50%) or 4 (42%) hours, usually with foam swabs (97%). Oral care was reported as a high priority (47%). Nurses with 7 years or more of critical care experience performed oral care more often (P=.008) than did less experienced nurses. Nurses with a bachelor's degree in nursing used foam swabs (P=.001), suctioned the mouth before the endotracheal tube (P=.02), and suctioned after oral care (P<.001) more often than other nurses. Nurses whose units had an oral care policy (72%) reported that the policy indicated using a toothbrush (63%), using toothpaste (40%), brushing with a foam swab (90%), using chlorhexidine gluconate oral rinse (49%), suctioning the oral cavity (84%), and assessing the oral cavity (73%). Oral care practices and policies differed for all those items.

CONCLUSIONS

Survey results indicate that discrepancies exist between reported practices and policies. Oral care policies appear to be present, but not well used.

Current Concepts in the Prevention and Treatment of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is one of the most common causes of infection in intensive care unit (ICU) patients. Efforts to prevent VAP have focused on both pharmacologic and nonpharmacologic strategies. Two of the more controversial pharmacologic approaches included selective decontamination of the digestive tract (SDD) and decontamination of the oropharynx using topical antimicrobials or antiseptics including chlorhexidine (CHX). Additionally, avoidance of pharmacotherapy-related risk factors is hypothesized to reduce VAP rates. Successful treatment of VAP is becoming increasingly difficult in the era of antibiotic resistance. Utilization of local antibiograms, implementation of standardized treatment pathways, and optimization of pharmacodynamic-based dosing offer methods to improve empiric therapy selections. De-escalation of therapy should be a constant focus in an attempt to reduce overall antibiotic consumption and the selection pressure on ICU flora, thus minimizing the development and spread of antimicrobial resistance in the ICU.

Prevention of ventilator-associated pneumonia in adults

Ventilator-associated pneumonia, broadly defined as pneumonia that develops after 48 hours of intubation, is a common mechanical ventilation complication that causes significant morbidity and mortality in critically ill patients. Prevention strategies are continually evolving to decrease the impact of this serious and costly disease.

"Does periodontal therapy reduce the risk for systemic diseases?"

Periodontal disease is treated by various approaches, including simple oral hygiene practices, professional mechanical debridement, antimicrobial therapy and periodontal surgery. There is evidence to associate periodontal disease with several systemic diseases and conditions, including myocardial infarction, adverse pregnancy outcomes, diabetes mellitus, and respiratory disease. This article reviews the published literature that describes the effects of periodontal treatment on cardiovascular diseases, adverse pregnancy outcomes, diabetes mellitus, and respiratory disease. While some progress has been made, further research is required to understand the value of periodontal interventions in the prevention of systemic diseases.

Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients

OBJECTIVE

To evaluate the effectiveness of the oral application of a 0.12% solution of chlorhexidine for prevention of respiratory tract infections among intensive care unit (ICU) patients.

DESIGN

The study design was a double-blind, randomized, placebo-controlled trial.

SETTING

The study was performed in an ICU in a tertiary care hospital at a public university. PATIENTS. Study participants comprised 194 patients admitted to the ICU with a prospective length of stay greater than 48 hours, randomized into 2 groups: those who received chlorhexidine (n = 98) and those who received a placebo (n = 96).

INTERVENTION

Oral rinses with chlorhexidine or a placebo were performed 3 times a day throughout the duration of the patient's stay in the ICU. Clinical data were collected prospectively.

RESULTS

Both groups displayed similar baseline clinical features. The overall incidence of respiratory tract infections (RR, 1.0 [95% confidence interval [CI], 0.63-1.60]) and the rates of ventilator-associated pneumonia per 1,000 ventilator-days were similar in both experimental and control groups (22.6 vs 22.3; P = .95). Respiratory tract infection-free survival time (7.8 vs 6.9 days; P = .61), duration of mechanical ventilation (11.1 vs 11.0 days; P = .61), and length of stay (9.7 vs 10.4 days; P = .67) did not differ between the chlorhexidine and placebo groups. However, patients in the chlorhexidine group exhibited a larger interval between ICU admission and onset of the first respiratory tract infection (11.3 vs 7.6 days; P = .05). The chances of surviving the ICU stay were similar (RR, 1.08 [95% CI, 0.72-1.63]).

CONCLUSION

Oral application of a 0.12% solution of chlorhexidine does not prevent respiratory tract infections among ICU patients, although it may retard their onset.

The paradox of ventilator-associated pneumonia prevention measures

There is a striking paradox in the literature supporting high-profile measures to reduce ventilator-associated pneumonia (VAP): many studies show significant reductions in VAP rates but almost none show any impact on patients' duration of mechanical ventilation, length of stay in the intensive care unit and hospital, or mortality. The paradox is largely attributable to lack of specificity in the VAP definition. The clinical and microbiological criteria for VAP capture a population of patients with an array of conditions that range from serious to benign. Many of the benign events are manifestations of bacterial colonization superimposed upon pulmonary edema, atelectasis, or other non-infectious processes. VAP prevention measures that work by decreasing bacterial colonization preferentially lower the frequency of these mislabelled, more benign events. In addition, misclassification obscures detection of an impact of prevention measures on bona fide pneumonias. Together, these effects create the possibility of the paradox where a prevention measure may have a large impact on VAP rates but minimal impact on patients' outcomes. The paradox makes changes in VAP rates alone an unreliable measure of whether VAP prevention measures are truly beneficial to patients and behooves us to measure their impact on patient outcomes before advocating their adoption.

Successful prevention of ventilator-associated pneumonia in an intensive care setting

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections (HAIs) in critical care settings.

OBJECTIVE

Our objective was to examine the effect of a series of interventions, implemented in 3 different periods to reduce the incidence of VAP in an intensive care unit (ICU).

METHODS

A quasiexperimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed during different phases. From March 2001 to December 2002 (phase 1: P1), some Centers for Disease Control and Prevention (CDC) evidence-based practices were implemented. From January 2003 to December 2006 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and, from January 2007 to September 2008 (P3), we continued P2 interventions and implemented the Institute for Healthcare Improvement's ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions.

RESULTS

The incidence density of VAP in the ICU per 1000 patient-days was 16.4 in phase 1, 15.0 in phase 2, and 10.4 in phase 3, P=.05. Getting to zero VAP was possible only in P3 when compliance with all interventions exceeded 95%.

CONCLUSION

These results suggest that reducing VAP rates to zero is a complex process that involves multiple performance measures and interventions.

Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control

BACKGROUND

Oral cleansing with chlorhexidine decreases the incidence of nosocomial pneumonia in patients after cardiac surgery. However, evidence of its benefit in ICU patients is conflicting.

METHODS

Patients admitted to the ICU of an Indian tertiary care teaching hospital were randomized to twice-daily oropharyngeal cleansing with 0.2% chlorhexidine or 0.01% potassium permanganate (control) solution. Effects on the incidence of nosocomial pneumonia during ICU stay (primary outcome) and length of ICU stay and in-hospital mortality (secondary outcomes) were studied.

RESULTS

Five hundred twelve patients were randomized to either the chlorhexidine group (n = 250) or the control group (n = 262). Of the 471 subjects who completed the protocol, nosocomial pneumonia developed in 16 of 224 subjects (7.1%) in the chlorhexidine group and 19 of 247 subjects (7.7%) in the control group (p = 0.82; relative risk, 0.93; 95% confidence interval, 0.49 to 1.76); intention-to-treat analysis of 21 patients in whom the cleansing protocol was not followed revealed similar results. There was no significant difference between the study and control groups in the median day of development of pneumonia (5.0 days: interquartile range [IQR], 3.0 to 7.7 vs 5.0 days: IQR, 3.0 to 6.0, respectively), median ICU stay (5.0 days: IQR, 3.0 to 8.0 vs 6.0 days: IQR, 3.0 to 8.0, respectively), and mortality (34.8% vs 28.3%, respectively). On subgroup analysis, there was no significant difference in the primary and secondary outcomes in patients on mechanical ventilation, tracheal intubation, and coma (Glasgow coma scale <or= 8). During the study period, nosocomial pneumonia developed in fewer subjects (35 of 471 subjects [7.4%]) than in the 3 months preceding and following the study (98 of 452 subjects [21.7%]; p < 0.001; relative risk, 0.34; 95% confidence interval, 0.24 to 0.49).

CONCLUSIONS

Oropharyngeal cleansing with 0.2% chlorhexidine solution was not superior to oral cleansing with the control solution. However, the decreased incidence of nosocomial pneumonia during the study period suggests a possible benefit of meticulous oral hygiene in ICU patients.

A randomized trial of dental brushing for preventing ventilator-associated pneumonia

BACKGROUND

Poor oral hygiene is associated with respiratory pathogen colonization and secondary lung infection. The impact of adding electric toothbrushing to oral care in order to reduce ventilator-associated pneumonia (VAP) incidence is unknown.

METHODS

The study design was a prospective, simple-blind, randomized trial of adult patients intubated for > 48 h. Controlling for exposure to antibiotic treatment, patients were randomized to oral care every 8 h with 0.12% chlorhexidine digluconate (standard group) or standard oral care plus electric toothbrushing (toothbrush group). VAP was documented by quantitative respiratory cultures. Mechanical ventilation (MV) duration, hospital ICU length of stay (LOS), antibiotic use, and hospital ICU mortality were secondary end points.

RESULTS

The study was terminated after randomizing 147 patients (74 toothbrush group) in a scheduled interim analysis. The two groups were comparable at baseline. The toothbrush group and standard group had similar rates of suspected VAP (20.3% vs 24.7%; p = 0.55). After adjustment for severity of illness and admission diagnosis, the incidence of microbiologically documented VAP was also similar in the two groups (hazard ratio, 0.84; 95% confidence interval, 0.41 to 1.73). The groups did not differ significantly in mortality, antibiotic-free days, duration of MV, or hospital ICU LOS.

CONCLUSIONS

Our findings suggest that the addition of electric toothbrushing to standard oral care with 0.12% chlorhexidine digluconate is not effective for the prevention of VAP.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00842478.

Use of the probiotic Lactobacillus plantarum 299 to reduce pathogenic bacteria in the oropharynx of intubated patients: a randomised controlled open pilot study

Introduction

Ventilator-associated pneumonia (VAP) is usually caused by aspiration of pathogenic bacteria from the oropharynx. Oral decontamination with antiseptics, such as chlorhexidine (CHX) or antibiotics, has been used as prophylaxis against this complication. We hypothesised that the probiotic bacteria Lactobacillus plantarum 299 (Lp299) would be as efficient as CHX in reducing the pathogenic bacterial load in the oropharynx of tracheally intubated, mechanically ventilated, critically ill patients.

Methods

Fifty critically ill patients on mechanical ventilation were randomised to either oral mechanical cleansing followed by washing with 0.1% CHX solution or to the same cleansing procedure followed by oral application of an emulsion of Lp299. Samples for microbiological analyses were taken from the oropharynx and trachea at inclusion and at defined intervals thereafter.

Results

Potentially pathogenic bacteria that were not present at inclusion were identified in oropharyngeal samples from eight of the patients treated with Lp299 and 13 of those treated with CHX (p = 0.13). Analysis of tracheal samples yielded similar results. Lp299 was recovered from the oropharynx of all patients in the Lp299 group.

Conclusions

In this pilot study, we found no difference between the effect of Lp299 and CHX used in oral care procedures, when we examined the effects of those agents on colonisation of potentially pathogenic bacteria in the oropharynx of intubated, mechanically ventilated patients.

Ventilator-associated tracheobronchitis: the impact of targeted antibiotic therapy on patient outcomes

Nosocomial lower respiratory tract infections are a common cause of morbidity and mortality in ICU patients receiving mechanical ventilation. Many studies have investigated the management and prevention of ventilator-associated pneumonia (VAP), but few have focused on the role of ventilator-associated tracheobronchitis (VAT). The pathogenesis of lower respiratory tract infections often begins with tracheal colonization that may progress to VAT, and in selected patients to VAP. Since there is no well-established definition of VAT, discrimination between VAT and VAP can be challenging. VAT is a localized disease with clinical signs (fever, leukocytosis, and purulent sputum), microbiologic information (Gram stain with bacteria and leukocytes, with either a positive semiquantitative or a quantitative sputum culture), and the absence of a new infiltrate on chest radiograph. Monitoring endotracheal aspirates has been used to identify and quantify pathogens colonizing the lower airway, to diagnose VAT or VAP, and to initiate early, targeted antibiotic therapy. Recent data suggest that VAT appears to be an important risk factor for VAP and that targeted antibiotic therapy for VAT may be a new paradigm for VAP prevention and better patient outcomes.