Antiseptic mouthwash, the nitrate-nitrite-nitric oxide pathway, and hospital mortality: a hypothesis generating review

Combination of inorganic nitrate and vitamin C prevents collagen-induced arthritis in rats by inhibiting pyroptosis

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease characterized by synovial inflammation, cartilage damage, and bone loss. Although effective treatments are currently lacking, early interventions hold promise for alleviating RA symptoms. Inorganic nitrates and vitamin C (VC) are essential bioactive substances abundant in fruits and vegetables. Notably, nitrates and VC exhibit synergistic effects in a series of physiological and pathological conditions. In this study, we aim to examine the combination of nitrate and VC for preventing RA in a collagen-induced arthritis (CIA) rat model. Nitrate partly reduced foot swelling and arthritis scores and was more effective when combined with VC. Histopathological and radiological analyses revealed that nitrate + VC treatment alleviated synovial hyperplasia and bone loss. Additionally, nitrate + VC lowered the levels of TNF-α and IL-1β in serum as well as synovial tissue, decreased the expression of NF-κB and reduced the number of macrophages in synovial tissue. Compared to the CIA group, nitrate + VC decreased the levels of NLRP3 and GSDMD in macrophages, thus inhibiting pyroptosis. According to in vitro experiments, nitrate inhibited the activation of the NLRP3/caspase-1/GSDMD pathway in macrophages by conversion into nitrite. VC reduced the expression and phosphorylation of NF-κB in macrophages and thus reduced the expression levels of TNF-α and IL-1β. Therefore, nitrate/nitrite and VC may exert synergistic effects by blocking the interaction between NF-κB and NLRP3, further alleviating the inflammation and pyroptosis of macrophages, which provides a new strategy for RA prevention.

Effect of different mouthwashes on ventilator-related outcomes and mortality in intensive care unit patients: A network meta-analysis

BACKGROUND

Ventilator-associated pneumonia is a common and life-threatening complication in intensive care unit (ICU) patients. Maintaining oral hygiene is crucial for reducing ventilator-associated pneumonia incidence. Various mouthwash solutions are used for oral care in ICU settings, but their comparative effectiveness remains unclear. This study aims to systematically evaluate and compare the efficacy and safety of commonly used mouthwashes for oral care in mechanically ventilated ICU patients.

METHODS

We searched PubMed, Web of Science, Embase, and Cochrane Library for randomised controlled trials (RCTs) comparing saline, chlorhexidine, sodium bicarbonate, oxidising agents, herbal extracts, and povidone-iodine for oral care in ventilated ICU patients. Outcomes included ventilator-associated pneumonia incidence, ICU mortality, duration of ventilation, and Escherichia coli fixed value. A network meta-analysis (NMA) was conducted to synthesise direct and indirect evidence. This study is registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols, 2023120028.

RESULTS

FourteenRCTs with 1644 participants were included. Oxidising agents showed a trend towards reducing the incidence of VAP compared to the control group (risk ratio: 0.24, 95% confidence interval: 0.05-1.10). Administration of saline was associated with a notable reduction in ICU mortality (risk ratio: 0.18, 95% confidence interval: 0.04-0.88) versus no mouthwash. No significant differences were observed in the duration of mechanical ventilation between chlorhexidine, povidone-iodine, and the control group.

CONCLUSIONS

Antimicrobial mouthwashes, especially chlorhexidine, pose potential risks in ICU patients; oxidising solutions demonstrate relative safety. Saline solution emerges as a promising alternative, associated with a significant reduction in mortality rates. However, the need for large, high-quality RCTs remains paramount to substantiate these findings and establish evidence-based oral-care protocols in ICU settings.

REGISTRATION

This study is registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols, 2023120028.

Skin injury: Associations with variables related to perfusion and pressure

Skin injuries are a major healthcare problem that are not well understood or prevented in the critically ill, suggesting that underappreciated variables are contributing. This pilot study tested the hypothesis that perfusion-related factors contribute to skin injuries diagnosed as hospital-acquired pressure injuries (HAPIs). A total of 533 adult patients were followed over 2574 critical care days (mean age 62.4, standard deviation (SD) 14.3 years, mean body mass index 30.4 (SD 7.4) kg/m2, 36.4% female). This was a secondary analysis of prospective, non-randomised clinical data from an intensive care unit at a large urban teaching hospital. Factors related to perfusion, specifically two or more infusions of vasopressors/inotropes, temporary mechanical circulatory support (MCS), extracorporeal membrane oxygenation, and durable MCS, were analysed to determine whether they were more strongly associated with HAPIs than immobility due to prolonged mechanical ventilation (>72 h) or operating room time (>6 h). Patients diagnosed with a HAPI had a statistically significant higher risk of being exposed to variables related to perfusion and immobility (P < 0.05 for each variable). Perfusion-related variables, except durable MCS, had a larger effect on skin breakdown (number needed to harm (NNH) 4-10) than immobility-associated variables (NNH 12-17). The finding that perfusion-related variables predicted HAPIs may warrant consideration of alternative diagnoses, such as skin failure due to impaired perfusion as a pathophysiological process that occurs concurrently with multisystem organ failure. Differentiation of skin injuries primarily from circulatory malfunction, rather than external pressure, may guide the development of more effective treatment and prevention protocols. This pilot study suggests that the contribution of perfusion to skin injuries should be explored further.

The 75-Year Anniversary of the Department of Physiology and Pharmacology at Karolinska Institutet-Examples of Recent Accomplishments and Future Perspectives

Karolinska Institutet is a medical university encompassing 21 departments distributed across three departmental or campus groups. Pharmacological research has a long and successful tradition at the institute with a multitude of seminal findings in the areas of neuronal control of vasodilatation, cardiovascular pharmacology, neuropsychopharmacology, receptor pharmacology, and pharmacogenomics that resulted in, among many other recognitions, two Nobel prizes in Physiology and Medicine, one in 1970 to Ulf von Euler for his discovery of the processes involved in storage, release, and inactivation of neurotransmitters and the other in 1982 to Sune Bergström and Bengt Samuelsson for their work on prostaglandins and the discovery of leukotrienes. Pharmacology at Karolinska Institutet has over the last decade been ranked globally among the top 10 according to the QS World University Ranking. With the Department of Physiology and Pharmacology now celebrating its 75-year anniversary, we wanted to take this as an opportunity to showcase recent research achievements and how they paved the way for current activities at the department. We emphasize examples from preclinical and clinical research where the dpartment's integrative environment and robust infrastructure have successfully facilitated the translation of findings into clinical applications and patient benefits. The close collaboration between preclinical scientists and clinical researchers across various disciplines, along with a strong network of partnerships within the department and beyond, positions us to continue leading world-class pharmacological research at the Department of Physiology and Pharmacology for decades to come. SIGNIFICANCE STATEMENT: Pharmacological research at Karolinska Institutet has a long and successful history. Given the 75-year anniversary of the Department of Physiology and Pharmacology, this perspective provides an overview of recent departmental achievements and future trajectories. For these developments, interdisciplinary and intersectoral collaborations and a clear focus on result translation are key elements to continue its legacy of world-leading pharmacological research.

Effects of an Isotonic Beetroot Drink on Power Output During Sprint Exercise and Jump Performance in Physically Active Individuals: A Randomized Crossover Trial

Exogenous nitrate ingestion can improve exercise performance. This study investigated whether an isotonic beetroot drink could improve jump and sprint performance in active individuals. Twenty-three physically active participants (17 males, 6 females) (mean ± SD; age: 26 ± 4 years; body mass index: 22.4 ± 1.9 kg/m2) completed a double-blind, randomized, cross-over study where they consumed 570mL of either beetroot juice drink (BR) or isotonic beetroot juice drink (ISO-BR) three hours before performing countermovement (CMJ) and standing broad jump (SBJ) tests and a 30-second all-out sprint on a cycle ergometer. Both drinks contained equal nitrate (12.9 mmol) and carbohydrate (6.1g per 100mL) content but differed in osmolality (BR: 420 mOsm/kg vs. ISO-BR: 315 mOsm/kg). Salivary total nitrate and nitrite concentrations (NOx) 3 hours post-ingestion were significantly higher after consuming ISO-BR than BR. ISO-BR significantly improved peak power output compared to BR by 3.9% (ISO-BR: 11.4 ± 2.5 W/kg vs. BR: 11.0 ± 2.3 W/kg, p = .04) but not time to peak power (ISO-BR: 2.8 ± 1.7 s vs. BR: 2.9 ± 1.6 s, p = .62) or mean power output (ISO-BR: 7.3 ± 1.5 W/kg vs. BR: 7.3 ± 1.5 W/kg, p = .37). There were no significant differences in CMJ or SBJ between trials (p > .05). Sensory evaluation indicated that ISO-BR was preferred by 91% (n = 21) of participants compared with BR (average score; ISO-BR: 5.52 vs. BR: 3.52, p < .05). An ISO-BR drink improved peak power output during sprint cycling but not jump performance compared with BR alone, potentially via increased NOx.

Facilitating Nitrite-Derived S-Nitrosothiol Formation in the Upper Gastrointestinal Tract in the Therapy of Cardiovascular Diseases

Cardiovascular diseases (CVDs) are often associated with impaired nitric oxide (NO) bioavailability, a critical pathophysiological alteration in CVDs and an important target for therapeutic interventions. Recent studies have revealed the potential of inorganic nitrite and nitrate as sources of NO, offering promising alternatives for managing various cardiovascular conditions. It is now becoming clear that taking advantage of enzymatic pathways involved in nitrite reduction to NO is very relevant in new therapeutics. However, recent studies have shown that nitrite may be bioactivated in the acidic gastric environment, where nitrite generates NO and a variety of S-nitrosating compounds that result in increased circulating S-nitrosothiol concentrations and S-nitrosation of tissue pharmacological targets. Moreover, transnitrosation reactions may further nitrosate other targets, resulting in improved cardiovascular function in patients with CVDs. In this review, we comprehensively address the mechanisms and relevant effects of nitrate and nitrite-stimulated gastric S-nitrosothiol formation that may promote S-nitrosation of pharmacological targets in various CVDs. Recently identified interfering factors that may inhibit these mechanisms and prevent the beneficial responses to nitrate and nitrite therapy were also taken into consideration.

Oral nitrate-reducing bacteria as potential probiotics for blood pressure homeostasis

Hypertension is a leading cause of morbidity and mortality worldwide and poses a major risk factor for cardiovascular diseases and chronic kidney disease. Research has shown that nitric oxide (NO) is a vasodilator that regulates vascular tension and the decrease of NO bioactivity is considered one of the potential pathogenesis of essential hypertension. The L-arginine-nitric oxide synthase (NOS) pathway is the main source of endogenous NO production. However, with aging or the onset of diseases, the function of the NOS system becomes impaired, leading to insufficient NO production. The nitrate-nitrite-NO pathway allows for the generation of biologically active NO independent of the NOS system, by utilizing endogenous or dietary inorganic nitrate and nitrite through a series of reduction cycles. The oral cavity serves as an important interface between the body and the environment, and dysbiosis or disruption of the oral microbiota has negative effects on blood pressure regulation. In this review, we explore the role of oral microbiota in maintaining blood pressure homeostasis, particularly the connection between nitrate-reducing bacteria and the bioavailability of NO in the bloodstream and blood pressure changes. This review aims to elucidate the potential mechanisms by which oral nitrate-reducing bacteria contribute to blood pressure homeostasis and to highlight the use of oral nitrate-reducing bacteria as probiotics for oral microbiota intervention to prevent hypertension.

A comprehensive review of Siraitia grosvenorii (Swingle) C. Jeffrey: chemical composition, pharmacology, toxicology, status of resources development, and applications

Siraitia grosvenorii (Swingle) C. Jeffrey (S. grosvenorii), a perennial indigenous liana from the Cucurbitaceae family, has historically played a significant role in southern China's traditional remedies for various ailments. Its dual classification by the Chinese Ministry of Health for both medicinal and food utility underscores its has the potential of versatile applications. Recent research has shed light on the chemical composition, pharmacological effects, and toxicity of S. grosvenorii. Its active ingredients include triterpenoids, flavonoids, amino acids, volatile oils, polysaccharides, minerals, vitamins, and other microconstituents. Apart from being a natural sweetener, S. grosvenorii has been found to have numerous pharmacological effects, including alleviating cough and phlegm, preventing dental caries, exerting anti-inflammatory and anti-allergic effects, anti-aging and anti-oxidative, hypoglycemic, lipid-lowering, anti-depression, anti-fatigue, anti-schizophrenic, anti-Parkinson, anti-fibrotic, and anti-tumor activities. Despite its versatile potential, there is still a lack of systematic research on S. grosvenorii to date. This paper aims to address this gap by providing an overview of the main active components, pharmacological efficacy, toxicity, current status of development and application, development dilemmas, and strategies for intensive exploitation and utilization of S. grosvenorii. This paper aims to serve as a guide for researchers and practitioners committed to exploiting the biological resources of S. grosvenorii and further exploring its interdisciplinary potential.

Dietary nitrate intake and association with markers of cardiometabolic risk in Iranian female adolescents

Dietary nitrates are thought to confer several cardiometabolic health benefits, including improvements in blood pressure and the plasma lipid profile. However, existing data from Iran is conflicting and there is a dearth of literature focusing on non-adult populations. A total of 988 adolescent girls were recruited from schools in different areas of Mashhad and Sabzevar, Iran. Dietary nitrate intake was assessed using a food frequency questionnaire and participants were categorized into quartiles based on this. Differences in participant characteristics between quartiles were assessed using one-way ANOVA and associations between total nitrate intake, nitrate intake from vegetables and cardiometabolic risk markers (blood lipid profile, fasting blood glucose, systolic and diastolic blood pressure) were assessed using linear regression. Nitrate intake from vegetables was positively correlated with triglycerides, even after adjusting for several variables (β = 0.086, 95% CI = 0.002-0.097; P = 0.043). Total nitrate intake was also significantly positively associated with serum triglycerides (β = 0.097, 95% CI = 0.010-0.084; P = 0.012); however, this relationship disappeared after adjusting for several variables. Significant interaction effects were observed between total nitrate intake, nitrate intake from vegetables, and vitamin C upon triglycerides (P < 0.01). No significant relationships were found between total nitrate intake, nitrate intake from vegetables, and other cardiometabolic risk markers. Our findings suggest there may be neutral or possibly detrimental cardiovascular effects of dietary nitrate and/or vitamin C intake which are not in agreement with contemporary literature and warrant further investigation.

Effects of preoperative oral care on bacterial colonisation and halitosis in patients undergoing elective surgery: A randomised controlled study

OBJECTIVES

To evaluate the effects of single-dose chlorhexidine oral care on bacterial colonisation and halitosis in patients undergoing elective surgery.

RESEARCH METHODOLOGY

We conducted a two-arm parallel, single-blinded, randomised controlled trial. The intervention group (n = 102) received preoperative oral care with 0.12% chlorhexidine gluconate, and the control group (n = 105) received standard care. The data of the microbiological cultures between the groups were compared at the time of tracheal intubation, at extubation and 30 min after surgery. The presence of halitosis was measured using a survey questionnaire administered to the anaesthesia nurses assigned to the patients.

RESULTS

At baseline, no significant differences were found between the intervention and control groups for bacterial colonisation or halitosis. After the intervention, there was no significant difference in microbiological culture, including gram-positive, gram-negative bacilli and cocci results, between the two groups (p > 0.05). The presence of halitosis in the intervention group was significantly lower than in the control group during intubation (p < 0.0001) and at 30 min after surgery (p < 0.02). Regression analysis indicated that receiving oral was protective towards halitosis, while poor oral health was a risk factor.

CONCLUSIONS

Preoperative oral care using a single dose of chlorhexidine significantly improved the patients' halitosis in the perioperative period, but no significant effect was found on bacterial colonisation. Further studies are needed regarding the safe use of chlorhexidine for oral care.

IMPLICATION FOR CLINICAL PRACTICE

Oral hygiene using chlorhexidine could be beneficial in improving halitosis for anaesthesia personnel who take care of intubated adult patients undergoing elective surgery with general anaesthesia.

The Effects of Antimicrobial Mouthwashes on Systemic Disease: What Is the Evidence?

The potential association between antimicrobial mouthwash use and systemic health has gained attention in recent years with reports highlighting how some common systemic conditions are influenced by the use of different types of mouthwashes. In this context, links between mouthwash use and cardiovascular disease, diabetes mellitus, oral cancer, Alzheimer's disease, and preeclampsia have been proposed, albeit with limited levels of evidence. Chlorhexidine mouthwash in particular has been the most widely studied agent while available data on other types of over-the-counter mouthwashes are generally scarce. Furthermore, there is currently no evidence-based recommendations on the appropriate use of mouthwashes during pregnancy. This article will present the current evidence on the association between mouthwash use and the aforementioned conditions with emphasis on the mechanisms that may underlie such an association.

From nitrate to NO: potential effects of nitrate-reducing bacteria on systemic health and disease

Current research has described improving multisystem disease and organ function through dietary nitrate (DN) supplementation. They have provided some evidence that these floras with nitrate (NO3-) reductase are mediators of the underlying mechanism. Symbiotic bacteria with nitrate reductase activity (NRA) are found in the human digestive tract, including the mouth, esophagus and gastrointestinal tract (GT). Nitrate in food can be converted to nitrite under the tongue or in the stomach by these symbiotic bacteria. Then, nitrite is transformed to nitric oxide (NO) by non-enzymatic synthesis. NO is currently recognized as a potent bioactive agent with biological activities, such as vasodilation, regulation of cardiomyocyte function, neurotransmission, suppression of platelet agglutination, and prevention of vascular smooth muscle cell proliferation. NO also can be produced through the conventional L-arginine-NO synthase (L-NOS) pathway, whereas endogenous NO production by L-arginine is inhibited under hypoxia-ischemia or disease conditions. In contrast, exogenous NO3-/NO2-/NO activity is enhanced and becomes a practical supplemental pathway for NO in the body, playing an essential role in various physiological activities. Moreover, many diseases (such as metabolic or geriatric diseases) are primarily associated with disorders of endogenous NO synthesis, and NO generation from the exogenous NO3-/NO2-/NO route can partially alleviate the disease progression. The imbalance of NO in the body may be one of the potential mechanisms of disease development. Therefore, the impact of these floras with nitrate reductase on host systemic health through exogenous NO3-/NO2-/NO pathway production of NO or direct regulation of floras ecological balance is essential (e.g., regulation of body homeostasis, amelioration of diseases, etc.). This review summarizes the bacteria with nitrate reductase in humans, emphasizing the relationship between the metabolic processes of this microflora and host systemic health and disease. The potential effects of nitrate reduction bacteria on human health and disease were also highlighted in disease models from different human systems, including digestive, cardiovascular, endocrine, nervous, respiratory, and urinary systems, providing innovative ideas for future disease diagnosis and treatment based on nitrate reduction bacteria.

Habitual dietary nitrate intake and cognition in the Australian Imaging, Biomarkers and Lifestyle Study of ageing: A prospective cohort study

BACKGROUND & AIMS

Dietary nitrate improves cardiovascular health via a nitric oxide (NO) pathway. NO is key to both cardiovascular and brain health. There is also a strong association between vascular risk factors and brain health. Dietary nitrate intake could therefore be associated with better cognitive function and reduced risk of cognitive decline. This is yet to be investigated. The aim of this study was to investigate the association between habitual intake of dietary nitrate from sources where nitrate is naturally present, and cognitive function, and cognitive decline, in the presence or absence of the apolipoprotein E (APOE) ε4 allele.

METHODS

The study included 1254 older adult participants of the Australian Imaging, Biomarkers and Lifestyle Study of Ageing who were cognitively normal at baseline. Plant-derived, vegetable-derived, animal derived nitrate (not including meat where nitrate is an allowed additive), and total nitrate intakes were calculated from baseline food frequency questionnaires using comprehensive nitrate databases. Cognition was assessed at baseline and every 18 months over a follow-up period of 126 months using a comprehensive neuropsychological test battery. Multivariable-adjusted linear mixed effect models were used to examine the association between baseline nitrate intake and cognition over the 126 months (median [IQR] follow-up time of 36 [18-72] months), stratified by APOE ε4 carrier status.

RESULTS

In non APOE ε4 carriers, for every 60 mg/day higher intake of plant-derived nitrate at baseline there was an associated higher language score [β (95% CI): 0.10 (0.01, 0.19)] over 126 months, after multivariable adjustments. In APOE ε4 carriers, there was an associated better episodic recall memory [0.24 (0.08, 0.41)] and recognition memory [0.15 (0.01, 0.30)] scores. Similar associations were seen for the intakes of vegetable-derived and total nitrate. Additionally, in APOE ε4 carriers, for every 6 mg/day higher intake of animal-derived nitrate (excluding meat with nitrate as an allowed additive) at baseline there was an associated higher executive function score [β (95% CI): 1.41 (0.42, 2.39)]. We did not find any evidence of an association between dietary nitrate intake and rate of cognitive decline.

CONCLUSION

Our results suggest that habitual intake of dietary nitrate from sources where nitrate is naturally present impacts cognitive performance in an APOE genotype contingent manner. Further work is needed to validate our findings and understand potential mechanisms underlying the observed effects.

Effect of an educational intervention on compliance with care bundle items to prevent ventilator-associated pneumonia

OBJECTIVES

We aimed to evaluate the effectiveness of our ventilator-associated pneumonia prevention bundle implemented by education of the nursing staff, and to describe the tendency of knowledge retention.

RESEARCH METHODOLOGY

A prospective, before-and-after study was performed. The ventilator-associated pneumonia prevention bundle was implemented through a single educational intervention of the nursing staff. The risk of ventilator-associated pneumonia over time was estimated using a Cox proportional cause-specific hazard model. Compliance to preventive measures was assessed at three time-points: before education, at three months and 12 months after education.

SETTING

A 29-bed mixed medical-surgical intensive care unit.

MAIN OUTCOME MEASURES

Ventilator-associate pneumonia incidence densities, the risk of ventilator-associated pneumonia, and compliance to preventive measures in the pre-implementation and post-implementation periods.

RESULTS

We analyzed the data of 251 patients. The incidence density of pneumonia decreased from 29.3/1000 to 15.3/1000 ventilator-days after the implementation of the prevention program. Patients in the post-implementation period had significantly lower risk to develop pneumonia (hazard ratio 0.34, 95 % confidence interval 0.19-0.61, p = 0.001). At 3 months of implementation, a significant improvement was detected to all the individual bundle components. Complete compliance increased from 16.2 % to 62.2 % (p < 0.001). Compliance with bundle components decreased to baseline levels after 12 months of implementation apart from head-of-bed elevation.

CONCLUSION

This study supports existing evidence that educational interventions improve compliance. The gained knowledge was well translated into clinical practice reflected by the decreasing ventilator-associated pneumonia rate. It may be assumed that a refresher educational session within 12 months after implementation is needed.

Effect of menthol lozenges after extubation on thirst, nausea, physiological parameters, and comfort in cardiovascular surgery patients: A randomized controlled trial

OBJECTIVES

To determine the effect of post-extubation oral menthol lozenges on thirst, nausea, physiological parameters, and comfort level in patients undergoing cardiovascular surgery.

RESEARCH METHODOLOGY/DESIGN

The study was a single-centre, randomized controlled trial.

SETTING

This study included 119 patients undergoing coronary artery bypass graft surgery in a training and research hospital. Patients in the intervention group (n = 59) received menthol lozenges at 30, 60, and 90 min after extubation. Patients in the control group (n = 60) received standard care and treatment.

MAIN OUTCOME MEASURES

The primary outcome of the study was the change in post-extubation thirst assessed by Visual Analogue Scale after using menthol lozenges compared to baseline. Secondary outcomes were changes in post-extubation physiological parameters and nausea severity assessed by Visual Analogue Scale compared to baseline, and comfort level assessed with Shortened General Comfort Questionnaire.

RESULTS

Between-group comparisons showed that the intervention group had significantly lower thirst scores at all time points and nausea at the first assessment (p < 0.05) and significantly higher comfort scores (p < 0.05) than the control group. There were no significant differences between the groups in physiological parameters at baseline or any of the postoperative assessments (p > 0.05).

CONCLUSION

In patients undergoing coronary artery bypass graft surgery, the use of menthol lozenges effectively increased comfort level by reducing post-extubation thirst and nausea, but had no effect on physiological parameters.

IMPLICATIONS FOR CLINICAL PRACTICE

Nurses should be vigilant for complaints such as thirst, nausea, and discomfort in patients after extubation. Nurses' administration of menthol lozenges to patients may help reduce post-extubation thirst, nausea, and discomfort.

Short-term effects of Chlorhexidine mouthwash and Listerine on oral microbiome in hospitalized patients

Introduction

Chlorhexidine (CHX) and essential oil containing mouthwashes like Listerine^® can improve oral hygiene via suppressing oral microbes. In hospitalized patients, CHX mouthwash reduces the incidence of ventilator-associated pneumonia. However, CHX use was also associated with increased mortality, which might be related to nitrate-reducing bacteria. Currently, no study determines oral bacteria targeted by essential oils mouthwash in hospitalized patients using a metagenomic approach.

Methods

We recruited 87 hospitalized patients from a previous randomized control study, and assigned them to three mouthwash groups: CHX, Listerine, and normal saline (control). Before and after gargling the mouthwash twice a day for 5-7 days, oral bacteria were examined using a 16S rDNA approach.

Results

Alpha diversities at the genus level decreased significantly only for the CHX and Listerine groups. Only for the two groups, oral microbiota before and after gargling were significantly different, but not clearly distinct. Paired analysis eliminated the substantial individual differences and revealed eight bacterial genera (including Prevotella, Fusobacterium, and Selenomonas) with a decreased relative abundance, while Rothia increased after gargling the CHX mouthwash. After gargling Listerine, seven genera (including Parvimonas, Eubacterium, and Selenomonas) showed a decreased relative abundance, and the magnitudes were smaller compared to the CHX group. Fewer bacteria targeted by Listerine were reported to be nitrate-reducing compared to the CHX mouthwash.

Discussion

In conclusion, short-term gargling of the CHX mouthwash and Listerine altered oral microbiota in our hospitalized patients. The bacterial genera targeted by the CHX mouthwash and Listerine were largely different and the magnitudes of changes were smaller using Listerine. Functional alterations of gargling CHX and Listerine were also different. These findings can be considered for managing oral hygiene of hospitalized patients.

Multifaceted interventions are likely to be more effective to increase adherence to the ventilator care bundle: A systematic review of strategies to improve care bundle compliance

BACKGROUND

The implementation of ventilator care bundles has remained suboptimal. However, it is unclear whether improving adherence has a positive relationship with patient outcomes.

OBJECTIVES

To identify the most effective implementation strategies to improve adherence to ventilator bundles and to investigate the relationship between adherence to ventilator bundles and patient outcomes.

METHODS

A systematic review followed the PRISMA guidelines. A systematic literature search from the inception of ventilator care bundles 2001 to January 2021 of relevant databases, screening and data extraction according to Cochrane methodology.

RESULTS

In total, 6035 records were screened, and 24 studies met the eligibility criteria. The implementation strategies were provider-level interventions (n = 15), included educational activities, checklist, and audit/feedback. Organizational-level interventions include (n = 8) included change of medical record system and multidisciplinary team. System-level intervention (n = 1) had motivation and reward. The most common strategies were education, checklists, audit feedback, which are probably effective in improving adherence. We could not perform a meta-analysis due to heterogeneity of the strategies and types of adherence measurement. Most studies (n = 7) had a high risk of bias. There were some conflicting results in determining the associations between adherence and patient outcomes because of the poor quality of the studies.

CONCLUSION

Multifaceted interventions are likely to be effective for consistent improvement in adherence. It remains uncertain whether improvements in adherence have positive outcomes on patients due to limited evidence of low to moderate uncertainty. We recommend the need for robust research methodology to assess the effectiveness of implementation strategies on improving adherence and patient outcomes.

Oral care in intensive care units: Lithuanian nurses' attitudes and practices

AIM

This study examines the attitudes and practices of ICU nurses towards the provision of oral care to their patients.

OBJECTIVE

We conducted this cross-sectional survey about oral health care practices in ICUs in Lithuania.

METHODS

We used a self-administered 20-item questionnaire to survey the current oral care practices, training, and attitudes of 108 nurses. The questionnaire was based on previous studies to gather information related to the attitudes, oral care practices, and training of ICU nurses. We used the chi-square test to analyze relationships between the categorical variables.

RESULTS

Most (88, 82%) of the nurses stated that oral care is important. Although most (83, 77%) had adequate training, a clear majority (98, 91%) of the nurses reported a willingness to learn more. Most (78, 72%) of the nurses found the oral cavity difficult to clean, and (71, 66%) found doing so unpleasant. When performing oral care, the nurses used mostly foam swabs (62, 61%) and moisturizers (54, 53%). More than half (57, 57%) of the nurses expressed a need for more hospital support.

CONCLUSIONS

Nurses working in ICUs reported that oral care is a high priority for their patients, but a difficult and unpleasant task. Nurses provided oral care mainly with toothbrushes, foam swabs, and moisturizers.

Anti-Inflammatory and Anti-Bacterial Effects of Mouthwashes in Intensive Care Units: A Systematic Review and Meta-Analysis

Mouthwashes are used as oral care for critical care patients to prevent infections. However, there are conflicting data concerning whether mouthwashes are needed as a part of daily oral care for critical care patients. This study aimed to evaluate the anti-inflammatory and anti-bacterial effects of mouthwashes for critical care patients. The PubMed, EMBASE, CENTRAL, and grey literature databases were searched by descriptors combining population (intensive care unit patients) and intervention (mouthwashes). After the screening, only randomized controlled trials (RCTs) evaluating the anti-inflammatory and anti-bacterial effects of mouthwashes in patient critical care were included. From the 1531 articles, 16 RCTs satisfied the eligibility criteria for systematic review and 10 were included in the meta-analyses. A significant difference was found in the incidence of ventilator associated pneumonia (VAP) (odds ratio [OR] 0.53, 95% confidential interval [95% CI] 0.33 to 0.86) between the mouthwash and placebo groups, while no significant difference was found in the mortality (OR 1.49, 95%CI 0.92 to 2.40); the duration of mechanical ventilation (weighted mean difference [WMD] -0.10, 95%CI -2.01 to 1.81); and the colonization of Staphylococcus aureus (OR 0.88, 95%CI 0.34 to 2.30), Escherichia coli (OR 1.19, 95%CI 0.50 to 2.82), and Pseudomonas aeruginosa (OR 1.16, 95%CI 0.27 to 4.91) between the two groups. In conclusion, mouthwashes were effective in decreasing the incidence of VAP. Thus, mouthwashes can be used as part of daily oral care for critical care patients.

Enhancement of Nitric Oxide Bioavailability by Modulation of Cutaneous Nitric Oxide Stores

The generation of nitric oxide (NO) in the skin plays a critical role in wound healing and the response to several stimuli, such as UV exposure, heat, infection, and inflammation. Furthermore, in the human body, NO is involved in vascular homeostasis and the regulation of blood pressure. Physiologically, a family of enzymes termed nitric oxide synthases (NOS) generates NO. In addition, there are many methods of non-enzymatic/NOS-independent NO generation, e.g., the reduction of NO derivates (NODs) such as nitrite, nitrate, and nitrosylated proteins under certain conditions. The skin is the largest and heaviest human organ and contains a comparatively high concentration of these NODs; therefore, it represents a promising target for many therapeutic strategies for NO-dependent pathological conditions. In this review, we give an overview of how the cutaneous NOD stores can be targeted and modulated, leading to a further accumulation of NO-related compounds and/or the local and systemic release of bioactive NO, and eventually, NO-related physiological effects with a potential therapeutical use for diseases such as hypertension, disturbed microcirculation, impaired wound healing, and skin infections.

Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies

Patients in intensive care units (ICUs) are at high risk for healthcare-acquired infections (HAI) due to the high prevalence of invasive procedures and devices, induced immunosuppression, comorbidity, frailty and increased age. Over the past decade we have seen a successful reduction in the incidence of HAI related to invasive procedures and devices. However, the rate of ICU-acquired infections remains high. Within this context, the ongoing emergence of new pathogens, further complicates treatment and threatens patient outcomes. Additionally, the SARS-CoV-2 (COVID-19) pandemic highlighted the challenge that an emerging pathogen provides in adapting prevention measures regarding both the risk of exposure to caregivers and the need to maintain quality of care. ICU nurses hold a special place in the prevention and management of HAI as they are involved in basic hygienic care, steering and implementing quality improvement initiatives, correct microbiological sampling, and aspects antibiotic stewardship. The emergence of more sensitive microbiological techniques and our increased knowledge about interactions between critically ill patients and their microbiota are leading us to rethink how we define HAIs and best strategies to diagnose, treat and prevent these infections in the ICU. This multidisciplinary expert review, focused on the ICU setting, will summarise the recent epidemiology of ICU-HAI, discuss the place of modern microbiological techniques in their diagnosis, review operational and epidemiological definitions and redefine the place of several controversial preventive measures including antimicrobial-impregnated medical devices, chlorhexidine-impregnated washcloths, catheter dressings and chlorhexidine-based mouthwashes. Finally, general guidance is suggested that may reduce HAI incidence and especially outbreaks in ICUs.

The oral microbiome, nitric oxide and exercise performance

The human microbiome comprises ∼10¹³-10¹⁴ microbial cells which form a symbiotic relationship with the host and play a critical role in the regulation of human metabolism. In the oral cavity, several species of bacteria are capable of reducing nitrate to nitrite; a key precursor of the signaling molecule nitric oxide. Nitric oxide has myriad physiological functions, which include the maintenance of cardiovascular homeostasis and the regulation of acute and chronic responses to exercise. This article provides a brief narrative review of the research that has explored how diversity and plasticity of the oral microbiome influences nitric oxide bioavailability and related physiological outcomes. There is unequivocal evidence that dysbiosis (e.g. through disease) or disruption (e.g. by use of antiseptic mouthwash or antibiotics) of the oral microbiota will suppress nitric oxide production via the nitrate-nitrite-nitric oxide pathway and negatively impact blood pressure. Conversely, there is preliminary evidence to suggest that proliferation of nitrate-reducing bacteria via the diet or targeted probiotics can augment nitric oxide production and improve markers of oral health. Despite this, it is yet to be established whether purposefully altering the oral microbiome can have a meaningful impact on exercise performance. Future research should determine whether alterations to the composition and metabolic activity of bacteria in the mouth influence the acute responses to exercise and the physiological adaptations to exercise training.

Is Chlorhexidine in Dentistry an Ally or a Foe? A Narrative Review

Chlorhexidine has been one of the most effective and popular antiseptic substances used in medicine for decades. In dentistry, it has been used in endodontics, periodontology, surgery, and general dentistry. It is also widely used daily by patients in mouth rinses, gels, or toothpastes. Because of its multiple uses, we should follow all types of research reporting its potential adverse effects. This article aims to review the most up-to-date studies regarding chlorhexidine and its possible side effects, in the period of the SARS-CoV-2 pandemic, as the use of different antiseptic substances has rapidly increased.

Contamination of antimicrobial-resistant bacteria on toothbrushes used with mechanically ventilated patients: A cross sectional study

OBJECTIVE

The purpose of this study was to determine pathogenic and antimicrobial-resistant bacteria on used toothbrushes of mechanically ventilated patients.

RESEARCH METHODOLOGY

A cross-sectional study was conducted by collecting toothbrushes used with mechanically ventilated patients. The total bacterial count on each toothbrush was assessed by culturing on Trypticase soy agar (TSA). Gram stain and biochemical testing were used to identify bacterial species. Antibiotic susceptibility of pathogenic bacteria was assessed by the Kirby-Bauer disk diffusion method.

RESULTS

Thirty-five toothbrushes (97%) had bacterial contamination, 27 toothbrushes had at least two bacterial species, and 13 toothbrushes harboured antimicrobial-resistant bacteria. The most commonly isolated bacteria were Klebsiella spp. (21%), followed by Acinetobacter baumannii (18%). Five isolates of A. baumannii, six isolates of K. pneumoniae, and two isolates of Enterobacter cloacae were multidrug-resistant (MDR) strains. Four isolates of K. pneumoniae were identified as extended-spectrum beta-lactamase (ESBL) producing strains, and two isolates of P. aeruginosa were extensively drug-resistant (XDR). The average total bacterial count was 10⁴-10⁵ CFU/toothbrush head.

CONCLUSIONS

Antimicrobial-resistant bacteria were detected on toothbrushes. Therefore, practice of toothbrush care should be reconsidered in associated to maintaining the oral hygiene of mechanically ventilated patients to prevent ventilator-associated pneumonia (VAP).

Oral mucosal mouthwash with chlorhexidine does not reduce the incidence of ventilator-associated pneumonia in critically ill children: A randomised controlled trial

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most frequently encountered causes of hospital-acquired infection and results in high morbidity among intubated patients. Few trials have investigated the efficacy of oral care with chlorhexidine (CHX) mouthwash for the prevention of VAP in the paediatric population.

OBJECTIVES

The objective of this study was to assess the efficacy of CHX mouthwash in the prevention of VAP and to determine risk factors for VAP in children aged 1 month to 18 years admitted to the paediatric intensive care unit (PICU).

METHODS

This was a prospective, randomised, controlled, double-blind trial performed in the PICU. Patients were randomised into two groups receiving CHX (0.12%) (n = 88) or placebo (0.9% NaCl) (n = 86) and were followed up for VAP development. The main outcome measures were incidence of VAP, duration of hospital stay, duration of PICU stay, duration of ventilation, mortality, and the characteristics of organisms isolated in cases with VAP.

RESULTS

No difference was observed in the incidence of VAP and the type and distribution of organisms in the two groups (p > 0.05). In the CHX and placebo groups, we identified 21 and 22 patients with VAP, respectively. Incidence per 1000 ventilation days was 29.5 events in the CHX group and 35.1 events in the placebo group. Gram-negative bacteria were most common (71.4% in CHX vs. 54.5% in placebo). The use of 0.12% CHX did not influence hospital stay, PICU stay, ventilation, and mortality (p > 0.05). Multivariate analysis identified duration of ventilation as the only independent risk factor for VAP (p = 0.001).

CONCLUSION

The use of 0.12% CHX did not reduce VAP frequency among critically ill children. The only factor that increased VAP frequency was longer duration on ventilation. It appears that low concentration of CHX is not effective for VAP prevention, especially in the presence of multiresistant bacteria. CLINICALTRIALS.

GOV IDENTIFIER

NCT04527276.

Oral probiotic and its delivery carriers to improve oral health: A review

In recent years, oral probiotics have been researched on their effectiveness in reducing and preventing oral diseases. Oral probiotics could be introduced into the oral cavity to keep the equilibrium of the microbiome. Hence, the delivery carrier for oral probiotics plays an important factor to ensure a high number of oral probiotics were delivered and released into the oral cavity. This review presents a brief overview of oral microbiota and the role of oral probiotics in reducing oral diseases. Moreover, important aspects of the oral probiotic product such as viability, adherence ability, health effects, safety, and delivery site were discussed. Besides that, the importance of utilizing indigenous oral probiotics was also emphasized. Oral probiotics are commonly found in the market in the form of chewing tablets, lozenges, and capsules. Hence, the oral probiotic carriers currently used in the market and research were reviewed. Furthermore, this review introduces new potential oral probiotic delivery carriers such as oral strip, bucco-adhesive gel, and mouthwash. Their effectiveness in delivering oral probiotics for oral health was also explored.

Association between perioperative chlorhexidine oral care and postoperative pneumonia in non-cardiac surgical patients: A systematic review and meta-analysis

BACKGROUND

Postoperative pneumonia is the third most common complication after surgery, and its occurrence is associated with a poor prognosis in patients. Perioperative chlorhexidine oral care has been reported to reduce the incidence of postoperative pneumonia in patients undergoing cardiac surgery. However, whether perioperative chlorhexidine oral care can reduce the incidence of postoperative pneumonia in noncardiac surgical patients is still unknown. The aim of this systematic review and meta-analysis was to determine the association between perioperative chlorhexidine oral care and postoperative pneumonia in noncardiac surgical patients.

METHODS

A comprehensive systematic search of PubMed, Ovid Embase, Web of Science, the Cochrane Library, Wanfang Database, and the China National Knowledge Infrastructure was conducted to include studies from the inception of each database through March 2021. The reference lists of all included studies were also searched by hand. Eligible studies were published and unpublished randomized controlled trials and observational studies evaluating the effect of perioperative chlorhexidine oral care on the reported incidence of postoperative pneumonia. Relative risks or odds ratio with their 95% confidence intervals were calculated and risk of bias was assessed for eligible studies.

RESULTS

Seven randomized controlled trials with a total of 1,773 patients and 3 observational studies with a total of 12,528 noncardiac surgical patients were included. A total of 621 and 5,904 patients received perioperative chlorhexidine oral care in randomized controlled trials and observational studies, respectively. Six (85%) randomized controlled trials had a high risk of bias, and 2 (67%) observational studies had a high quality. Perioperative chlorhexidine oral care significantly reduced the incidence of postoperative pneumonia in randomized controlled trials (relative risk, 0.60; 95% confidence interval, 0.44-0.80; P < .001) and observational studies (odds ratio, 0.26; 95% confidence interval, 0.08-0.90; P = .03).

CONCLUSION

Perioperative chlorhexidine oral care led by a nurse significantly decreases the incidence of postoperative pneumonia in noncardiac surgical patients and may be more convenient and economical compared with dental professional-led perioperative oral care.

Impact of oral care on thirst perception and dry mouth assessments in intensive care patients: An observational study

OBJECTIVES

To investigate the impact of oral care on thirst perception and dry mouth assessments.

RESEARCH DESIGN

Single-centre observational study.

SETTING

Intensive care unit in a university hospital.

MAIN OUTCOME

We assessed thirst perception and dry mouth in adult patients before and after oral care. Thirst perception was assessed using a numerical rating scale and dry mouth was assessed using an oral moisture checking device and the modified Revised Oral Assessment Guide including tongue, mucous membranes and saliva.

RESULTS

Eighty-six patients were included. After oral care, thirst scores decreased by 1 (0 to 3, p < 0.01) and remained low only for one hour. Oral moisture was maintained at a normal level ≥ 27.0%, and mROAG was at a low level ≤ 4 before and after the oral care. The numerical rating score did not correlate with oral moisture (ρ = -0.01, p = 0.96) or the modified revised oral assessment guide (ρ = 0.09, p = 0.42). Among patients with thirst, 60 (70%) patients complained of thirst at the assessment timepoints, but only 17 (20%) patients complained independently.

CONCLUSION

Thirst perception was dissociated from dry mouth before and after oral care. Thirst must be frequently assessed and treated.