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&NA;. Early intervention with empirical antibacterials is essential in the treatment of ventilator-associated pneumonia. DRUGS & THERAPY PERSPECTIVES 2011. [DOI: 10.2165/11601610-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Abstract
PURPOSE OF REVIEW A multidisciplinary approach to the treatment and management of biofilms has resulted from the growing appreciation of the role that biofilms play in modern medicine. Conventional antimicrobial agents are generally ineffective against biofilms, and as a result novel laboratory-based and clinical strategies have emerged. The purpose of this review is to analyse the recent literature relating to novel treatment strategies targeting the growing spectrum of clinically relevant biofilms. RECENT FINDINGS Microscopy and molecular techniques have provided greater insights into identifying the key bacterial and fungal biofilm pathogens. Knowledge of these microorganisms has provided a foundation for the development of specific molecules, often microbial derived, with antimicrobial and/or biofilm disruptive properties, augmenting conventional antibiotics treatments. The validity of some such rationally designed therapeutics has been explored in clinical trials. SUMMARY Biofilms are inherently difficult to treat, and mechanical disruption is the mainstay of clinical management. With scientific progress in molecular microbiology, there is an abundance of newly discovered molecules and pathways, providing novel therapeutic and prophylactic targets.
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103
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Vincent JL, de Souza Barros D, Cianferoni S. Diagnosis, management and prevention of ventilator-associated pneumonia: an update. Drugs 2011; 70:1927-44. [PMID: 20883051 DOI: 10.2165/11538080-000000000-00000] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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104
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Meyer E, Schwab F, Gastmeier P. Nosocomial methicillin resistant Staphylococcus aureus pneumonia - epidemiology and trends based on data of a network of 586 German ICUs (2005-2009). Eur J Med Res 2011; 15:514-24. [PMID: 21163726 PMCID: PMC3352100 DOI: 10.1186/2047-783x-15-12-514] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The epidemiology of MRSA pneumonia varies across countries. One of the most import risk factors for the development of nosocomial MRSA pneumonia is mechanical ventilation. Methicillin resistance in S. aureus ventilator associated pneumonia (VAP) ranged between 37% in German, 54% in the US American and 78% in Asian and Latin American ICUs. In 2009, the incidence density of nosocomial VAP caused by MRSA was 0.28 per 1000 ventilation days in a network of 586 German ICUs. Incidences peaked in neurological and neurosurgical ICUs. Crude hospital mortality in studies performed after 2005 lay between 27% and 59% and attributable MRSA pneumonia mortality at 40%. Since 2005, US American and German data indicate decreasing trends for MRSA pneumonia. Measures to reduce MRSA pneumonia or to control the spread of MRSA include hand hygiene, standard and contact precautions, oral contamination with chlor hexidine, skin decontamination with antiseptics, screening, and (possibly) patient isolation in a single room.
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Affiliation(s)
- Elisabeth Meyer
- Institute of Hygiene and Environmental Medicine, Charité University Medicine, Hindenburgdamm 27, 12203 Berlin, Germany.
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105
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Needleman IG, Hirsch NP, Leemans M, Moles DR, Wilson M, Ready DR, Ismail S, Ciric L, Shaw MJ, Smith M, Garner A, Wilson S. Randomized controlled trial of toothbrushing to reduce ventilator-associated pneumonia pathogens and dental plaque in a critical care unit. J Clin Periodontol 2011; 38:246-52. [PMID: 21223352 DOI: 10.1111/j.1600-051x.2010.01688.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM To investigate the effect of a powered toothbrush on colonization of dental plaque by ventilator-associated pneumonia (VAP)-associated organisms and dental plaque removal. MATERIALS AND METHODS Parallel-arm, single-centre, examiner- and analyst-masked randomized controlled trial. Forty-six adults were recruited within 48 h of admission. Test intervention: powered toothbrush, control intervention: sponge toothette, both used four times per day for 2 min. Groups received 20 ml, 0.2% chlorhexidine mouthwash at each time point. RESULTS The results showed a low prevalence of respiratory pathogens throughout with no statistically significant differences between groups. A highly statistically significantly greater reduction in dental plaque was produced by the powered toothbrush compared with the control treatment; mean plaque index at day 5, powered toothbrush 0.75 [95% confidence interval (CI) 0.53, 1.00], sponge toothette 1.35 (95% CI 0.95, 1.74), p=0.006. Total bacterial viable count was also highly statistically significantly lower in the test group at day 5; Log(10) mean total bacterial counts: powered toothbrush 5.12 (95% CI 4.60, 5.63), sponge toothette 6.61 (95% CI 5.93, 7.28), p=0.002. CONCLUSIONS Powered toothbrushes are highly effective for plaque removal in intubated patients in a critical unit and should be tested for their potential to reduce VAP incidence and health complications.
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Affiliation(s)
- Ian G Needleman
- Unit of Periodontology, International Centre for Evidence-Based Oral Health, UCL Eastman Dental Institute, London, UK.
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106
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Gomes-Filho IS, Passos JS, Seixas da Cruz S. Respiratory disease and the role of oral bacteria. J Oral Microbiol 2010; 2:10.3402/jom.v2i0.5811. [PMID: 21523216 PMCID: PMC3084574 DOI: 10.3402/jom.v2i0.5811] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The relationship between oral health and systemic conditions, including the association between poor oral hygiene, periodontal disease, and respiratory disease, has been increasingly debated over recent decades. A considerable number of hypotheses have sought to explain the possible role of oral bacteria in the pathogenesis of respiratory diseases, and some clinical and epidemiological studies have found results favoring such an association. This review discusses the effect of oral bacteria on respiratory disease, briefly introduces the putative biological mechanisms involved, and the main factors that could contribute to this relationship. It also describes the role of oral care for individuals who are vulnerable to respiratory infections.
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Affiliation(s)
| | - Johelle S. Passos
- Department of Periodontics, Feira de Santana State University, Bahia, Brazil
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107
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Harbarth S, Haustein T. Year in review 2009: Critical Care--infection. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:240. [PMID: 21122168 PMCID: PMC3220050 DOI: 10.1186/cc9268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In 2009 Critical Care provided important and clinically relevant research data for management and prevention of infections in critically ill patients. The present review summarises the results of these observational studies and clinical trials and discusses them in the context of the current relevant scientific and clinical background. In particular, we discuss recent epidemiologic data on nosocomial infections in intensive care units, present new approaches to prevention of ventilator-associated pneumonia, describe recent advances in biomarker-guided antibiotic stewardship and attempt to briefly summarise specific challenges related to the management of infections caused by multidrug-resistant microorganisms and influenza A (H1N1).
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Affiliation(s)
- Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Medical School, 4 rue G-P-G, CH-1211 Geneva 14, Switzerland.
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108
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[Results of studies in critical care medicine in the year 2009 : update]. Anaesthesist 2010; 59:453-76. [PMID: 20405095 DOI: 10.1007/s00101-010-1718-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Critical care medicine plays an important role for the medical and economic success of hospitals. Knowledge and implementation of recent relevant studies are prerequisites for high quality intensive care medicine. The aim of the present manuscript is to present an overview of the most important publications in intensive care medicine in 2009 and comment on their clinical relevance. It has to be recognized that the cited studies are chosen according to the view of the authors. In 2009 many large randomized studies with high patient numbers were published. Main topics in 2009 were the therapy of lung failure, analgosedation and sepsis therapy. New trends are bedside echocardiography and telemedicine. Unfortunately, a magic bullet has not been identified last year. The focus is still on team education and guideline-assisted therapy.
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Carvajal C, Pobo A, Díaz E, Lisboa T, Llauradó M, Rello J. [Oral hygiene with chlorhexidine on the prevention of ventilator-associated pneumonia in intubated patients: a systematic review of randomized clinical trials]. Med Clin (Barc) 2010; 135:491-7. [PMID: 20557902 DOI: 10.1016/j.medcli.2010.02.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 02/02/2010] [Accepted: 02/04/2010] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Carlos Carvajal
- Unidad de Cuidados Intensivos, Fundación Clínica Shaio, Bogotá, Colombia
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111
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Kolahi J, Abrishami M, Fazilati M, Soolari A. Chlorhexidine rinse for prevention of urethritis in men linked to oral sex. Int Arch Med 2010; 3:9. [PMID: 20540731 PMCID: PMC2892434 DOI: 10.1186/1755-7682-3-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 06/11/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral sex among teenagers is on the rise. Similarity between the oral flora and organisms recovered from nongonococcal urethritis and prostatitis, points to retrograde entry of bacteria from oral cavity into the urethra following insertive oral intercourse. PRESENTATION OF THE HYPOTHESIS Chlorhexidine has a wide spectrum of anti-bactericidal activity encompassing gram positive and negative bacteria. It is also effective against HIV and HBV. It produced large and prolonged reductions in salivary bacterial counts within 7-h of its use. Hence, it would seem logic to postulate that rinsing with chlorhexidine before oral sex will be effective for prevention of retrograde entry of bacteria from oral cavity into the urethra. The recommendation for rinsing will be: 15 ml of a 0.12% or 10 ml of 0.2% chlorhexidine rinse for 30 seconds. Also other drug delivery systems such as chlorhexidine chewing gum or spray can be used. TESTING THE HYPOTHESIS Men suffering from recurrent nongonococcal urethritis or prostatitis are good subjects for testing the hypothesis. They perform genital safe sex via consistent use of condom. Yet they generally received unprotected insertive oral intercourse. Chlorhexidine can be used for prevention of recurrences of the disease. IMPLICATIONS OF THE HYPOTHESIS The chlorhexidine will be a new, easy, attractive and effective method for reduction of nongonococcal urethritis, prostatitis and epidydimitis following insertive oral intercourse. It is poorly absorbed from skin, mucosa and gastrointestinal tract indicating systemic safety of chlorhexidine. The agent does not cause any bacterial resistance and supra-infection.
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Affiliation(s)
- Jafar Kolahi
- Department of Periodontology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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112
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Prescott HC, O'Brien JM. Prevention of ventilator-associated pneumonia in adults. F1000 MEDICINE REPORTS 2010; 2. [PMID: 20948871 PMCID: PMC2948395 DOI: 10.3410/m2-15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Hallie C Prescott
- Department of Internal Medicine, The Ohio State University 395 West 12th Avenue, Columbus, OH 43210 USA
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113
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Scannapieco FA, Dasanayake AP, Chhun N. "Does periodontal therapy reduce the risk for systemic diseases?". Dent Clin North Am 2010; 54:163-81. [PMID: 20103479 DOI: 10.1016/j.cden.2009.10.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Frank A Scannapieco
- Department of Oral Biology, School of Dental Medicine, University at Buffalo, The State University of New York, Foster Hall, Buffalo, NY 14214, USA.
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114
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Panchabhai TS, Dangayach NS. Role of chlorhexidine gluconate in ventilator-associated pneumonia prevention strategies in ICU patients: where are we headed? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:427. [PMID: 20017886 PMCID: PMC2811949 DOI: 10.1186/cc8165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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115
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Derde LPG, Bonten MJM. Oropharyngeal decontamination in intensive care patients: less is not more. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:183. [PMID: 19735585 PMCID: PMC2784342 DOI: 10.1186/cc8013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a common cause of morbidity, antibiotic use, increased length of stay and, possibly, increased mortality in ICU patients. Colonization of the oropharyngeal cavity with potentially pathogenic micro-organisms is instrumental in the pathogenesis of VAP, and selective oropharyngeal decontamination (SOD) with antibiotics (AB-SOD) or antiseptics, such as chlorhexidine gluconate (CHX-SOD), has been associated with reduced incidences of VAP. In a recent issue of Critical Care Scannapieco and colleagues investigated differences in oropharyngeal colonization between mechanically ventilated patients receiving oropharyngeal decontamination with 0.12% CHX-SOD either once or twice daily compared to placebo. CHX-SOD was associated with a reduction in Staphylococcus aureus colonization, but the study was underpowered to demonstrate a reduction in VAP incidence. We urgently need well-designed and adequately powered studies to evaluate the potential benefits of CHX-SOD on patient outcome in ICUs.
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Affiliation(s)
- Lennie P G Derde
- Julius Center for Health Sciences and Primary Care, Heidelberglaan 100, Location Stratenum, 3584 CX Utrecht, The Netherlands.
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