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Kubo A, Sakai K, Ueki S, Fujita K. Effect of perioperative oral care on postoperative infections in patients with cancer: A systematic review and meta-analysis. Jpn J Nurs Sci 2024; 21:e12600. [PMID: 38757361 DOI: 10.1111/jjns.12600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/19/2024] [Accepted: 04/08/2024] [Indexed: 05/18/2024]
Abstract
AIM This systematic review aimed to assess the effect of non-pharmacologic perioperative oral hygiene care on reduced incidence of postoperative pneumonia (PP), surgical site infection (SSI), and the length of hospital stay in patients with cancer, and to describe the details of oral hygiene care. METHODS We searched seven databases. Eligibility criteria were based on perioperative oral hygiene care provided by healthcare professionals to patients aged ≥18 years who were surgically treated under general anesthesia and were evaluated for the incidence of PP and SSI. We reported risk ratios (RR) for dichotomous outcomes for PP and SSI using a fixed-effects model of meta-analysis. RESULTS The search resulted in 850 articles, among which two were randomized controlled trials (RCTs) and 21 were observational studies. Most studies indicated that dentists and medical care providers performed a combination of oral cleaning, and oral hygiene instructions. In RCTs, perioperative oral hygiene care significantly reduced the incidence of PP (RR, 0.86; p = .60), while in observational studies, perioperative oral hygiene care significantly reduced the incidence of PP (RR, 0.55; p < .001) and SSI (RR, 0.47; p < .001). The length of hospital stay was also significantly reduced (p < .05). However, the effectiveness of nursing intervention was not clear. CONCLUSIONS Perioperative oral hygiene care implemented by healthcare professionals prevented PP and SSI and reduced length of hospital stays for patients after cancer surgery. As daily perioperative oral hygiene care is performed by nurses, it is necessary to research the effects of oral hygiene by nurses in the future.
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Affiliation(s)
- Aoi Kubo
- Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kumiko Sakai
- Department of Health Sciences, Graduate School of Medicine, Kyushu university, Fukuoka, Japan
| | - Shingo Ueki
- Department of Health Sciences, Graduate School of Medicine, Kyushu university, Fukuoka, Japan
| | - Kimie Fujita
- Department of Health Sciences, Graduate School of Medicine, Kyushu university, Fukuoka, Japan
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Simmons JSC, Bourgault AM, Sole ML, Peach BC. A Review of Chlorhexidine Oral Care in Patients Receiving Mechanical Ventilation. Crit Care Nurse 2024; 44:45-53. [PMID: 38821530 DOI: 10.4037/ccn2024995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND Chlorhexidine gluconate has been considered the criterion standard of oral care for patients receiving mechanical ventilation because of its ability to reduce the incidence of ventilator-associated events. Optimal concentrations and frequencies remain unclear, as do adverse events related to mortality in various intensive care unit populations. OBJECTIVE To examine the current evidence for the efficacy of chlorhexidine gluconate in reducing the incidence of ventilator-associated events, mortality, intensive care unit length of stay, and duration of mechanical ventilation in patients receiving ventilator support. METHODS In this integrative review, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and Health Source: Nursing/Academic Edition were searched using terms related to mechanical ventilation and chlorhexidine gluconate oral care with dates ranging from 2012 to 2023. RESULTS Seventeen articles were included in this review: 8 systematic reviews, 8 randomized clinical trials (3 of which were not included in any systematic review), and 1 quasi-experimental study. Chlorhexidine gluconate oral care was associated with a reduced incidence of ventilator-associated events, but efficacy depended on concentration and frequency of administration. With stratification by intensive care unit population type, a nonsignificant trend toward increased mortality was found among non-cardiac surgical patients who received this care. CONCLUSION The evidence regarding the efficacy of chlorhexidine gluconate oral care in reducing ventilator-associated events in specific intensive care unit populations is contradictory. Recently published guidelines recommend de-implementation of chlorhexidine gluconate oral care in all patients receiving mechanical ventilation. Such care may be beneficial only in the cardiac surgical population.
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Affiliation(s)
| | - Annette M Bourgault
- Annette M. Bourgault is an associate professor, University of Central Florida College of Nursing. She is the Editor of Critical Care Nurse journal
| | - Mary Lou Sole
- Mary Lou Sole is the Dean and a professor, University of Central Florida College of Nursing
| | - Brian C Peach
- Brian C. Peach is an assistant professor, University of Central Florida College of Nursing
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Dos Santos AA, Silva LDDA, Santos CCDO, Fonseca-Silva T. Oral care practices for patients in intensive care unit: A systematic review. Int J Dent Hyg 2024. [PMID: 38764150 DOI: 10.1111/idh.12822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/27/2024] [Accepted: 05/04/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVES To critically analyse and discuss oral hygiene protocols in the hospital environment in patients admitted to the ICU, through a systematic review of the literature. METHODS The electronic search was performed on Pubmed, Cochrane, Web of Science and Google Scholar databases. The indexing keywords according to the PRISMA protocol were: 'hospital dentistry', 'oral health', 'oral care' and 'intensive care unit'. RESULTS The initial search resulted in a total of 2671 articles. Pre-selection based on titles led to the exclusion of 2510 articles and the remaining 36 were selected for abstract reading. After analysing the eligibility of the articles, eight studies were included in the review and submitted to qualitative analysis. CONCLUSION It can be concluded that cleaning with a soft bristle brush, use of chlorhexidine and lip moisturizing are methods commonly used in dental care actions in patients hospitalized in intensive care units.
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Affiliation(s)
- Aline Aparecida Dos Santos
- Post-graduate Program in Dentistry, Department of Dentistry, School of Biological and Health Sciences, Universidade Federal dos Vales do Jequitinhonha e Mucuri - UFVJM, Diamantina, Minas Gerais, Brazil
| | - Larissa Doalla de Almeida Silva
- Post-graduate Program in Dentistry, Department of Dentistry, School of Biological and Health Sciences, Universidade Federal dos Vales do Jequitinhonha e Mucuri - UFVJM, Diamantina, Minas Gerais, Brazil
| | - Carolina Carvalho de Oliveira Santos
- Post-graduate Program in Dentistry, Department of Dentistry, School of Biological and Health Sciences, Universidade Federal dos Vales do Jequitinhonha e Mucuri - UFVJM, Diamantina, Minas Gerais, Brazil
| | - Thiago Fonseca-Silva
- Post-graduate Program in Dentistry, Department of Dentistry, School of Biological and Health Sciences, Universidade Federal dos Vales do Jequitinhonha e Mucuri - UFVJM, Diamantina, Minas Gerais, Brazil
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De Cassai A, Pettenuzzo T, Busetto V, Legnaro C, Pretto C, Rotondi A, Boscolo A, Sella N, Munari M, Navalesi P. Chlorhexidine is not effective at any concentration in preventing ventilator-associated pneumonia: a systematic review and network meta-analysis. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:30. [PMID: 38702835 PMCID: PMC11067293 DOI: 10.1186/s44158-024-00166-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Oral chlorhexidine has been widely used for ventilator-associated pneumonia prevention in the critical care setting; however, previous studies and evidence synthesis have generated inconsistent findings. Our study aims to investigate if different concentrations of oral chlorhexidine may be effective in preventing such complication in intensive care unit patients. METHODS After pre-registration (Open Science Framework: 8CUKF), we conducted a network meta-analysis with the following PICOS: adult patients (age > 18 years old) undergoing invasive mechanical ventilation admitted in ICU (P); any concentration of chlorhexidine used for oral hygiene (I); placebo, sham intervention, usual care, or no intervention (C); rate of VAP (primary outcome), mechanical ventilation length, ICU length of stay (LOS), hospital LOS, mortality (secondary outcomes) (O); randomized controlled trials (S). We used the following database: PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and EMBASE without any limitation in publication date or language. RESULTS Chlorhexidine did not demonstrate any significant advantage over the control group in preventing ventilator-associated pneumonia or reducing mortality, duration of mechanical ventilation, length of stay in the intensive care unit, or overall mortality. CONCLUSIONS Chlorhexidine oral decontamination does not reduce the rate of ventilator-associated pneumonia in critically ill adult patients and its routine use could not be recommended. TRIAL REGISTRATION Registration number: Open Science Framework: 8CUKF.
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Affiliation(s)
- Alessandro De Cassai
- Sant'Antonio Anesthesia and Intensive Care Unit, University Hospital of Padua, Padua, Italy.
| | - Tommaso Pettenuzzo
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
| | - Veronica Busetto
- Cardiac Surgery Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | | | - Chiara Pretto
- Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Alessio Rotondi
- Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Annalisa Boscolo
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
- Department of Medicine - DIMED, University of Padova, Padua, Italy
- Thoracic Surgery and Lung Transplant Unit - Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Nicolò Sella
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
| | - Marina Munari
- Sant'Antonio Anesthesia and Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Paolo Navalesi
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
- Department of Medicine - DIMED, University of Padova, Padua, Italy
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Lorente L, Sabater-Riera J, Rello J. Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events. Expert Rev Anti Infect Ther 2024; 22:317-332. [PMID: 38642072 DOI: 10.1080/14787210.2024.2345877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP. AREAS COVERED This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles. EXPERT OPINION Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Spain
| | - Joan Sabater-Riera
- IDIBELL, Hospitalet de Llobregat, Spain, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Jordi Rello
- CRIPS (Clinical Research in Pneumonia & Sepsis); Vall d'Hebron Institute of Research, Barcelona, Spain
- Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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Póvoa P, Ramirez P, Blot S. Decolonization strategies against multidrug resistant organisms in the ICU. Intensive Care Med 2024; 50:577-579. [PMID: 38498166 DOI: 10.1007/s00134-024-07360-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/14/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Pedro Póvoa
- NOVA Medical School, NOVA University of Lisbon, Lisbon, Portugal.
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark.
- ICU4, Department of Intensive Care, Hospital de São Francisco Xavier, ULSLO, Estrada do Forte do Alto do Duque, 1449-005, Lisbon, Portugal.
| | - Paula Ramirez
- Department of Critical Care Medicine, Hospital Universitario Y Politécnico La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CibeRes, Carlos III Research Institute, CB06/06/0028, Madrid, Spain
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
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Ehrenzeller S, Klompas M. Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia: A Systematic Review and Meta-Analysis. JAMA Intern Med 2024; 184:131-142. [PMID: 38109100 PMCID: PMC10728803 DOI: 10.1001/jamainternmed.2023.6638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/11/2023] [Indexed: 12/19/2023]
Abstract
Importance Hospital-acquired pneumonia (HAP) is the most common and morbid health care-associated infection, but limited data on effective prevention strategies are available. Objective To determine whether daily toothbrushing is associated with lower rates of HAP and other patient-relevant outcomes. Data Sources A search of PubMed, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and 3 trial registries was performed from inception through March 9, 2023. Study Selection Randomized clinical trials of hospitalized adults comparing daily oral care with toothbrushing vs regimens without toothbrushing. Data Extraction and Synthesis Data extraction and risk of bias assessments were performed in duplicate. Meta-analysis was performed using random-effects models. Main Outcomes and Measures The primary outcome of this systematic review and meta-analysis was HAP. Secondary outcomes included hospital and intensive care unit (ICU) mortality, duration of mechanical ventilation, ICU and hospital lengths of stay, and use of antibiotics. Subgroups included patients who received invasive mechanical ventilation vs those who did not, toothbrushing twice daily vs more frequently, toothbrushing provided by dental professionals vs general nursing staff, electric vs manual toothbrushing, and studies at low vs high risk of bias. Results A total of 15 trials met inclusion criteria, including 10 742 patients (2033 in the ICU and 8709 in non-ICU departments; effective population size was 2786 after shrinking the population to account for 1 cluster randomized trial in non-ICU patients). Toothbrushing was associated with significantly lower risk for HAP (risk ratio [RR], 0.67 [95% CI, 0.56-0.81]) and ICU mortality (RR, 0.81 [95% CI, 0.69-0.95]). Reduction in pneumonia incidence was significant for patients receiving invasive mechanical ventilation (RR, 0.68 [95% CI, 0.57-0.82) but not for patients who were not receiving invasive mechanical ventilation (RR, 0.32 [95% CI, 0.05-2.02]). Toothbrushing for patients in the ICU was associated with fewer days of mechanical ventilation (mean difference, -1.24 [95% CI, -2.42 to -0.06] days) and a shorter ICU length of stay (mean difference, -1.78 [95% CI, -2.85 to -0.70] days). Brushing twice a day vs more frequent intervals was associated with similar effect estimates. Results were consistent in a sensitivity analysis restricted to 7 studies at low risk of bias (1367 patients). Non-ICU hospital length of stay and use of antibiotics were not associated with toothbrushing. Conclusions The findings of this systematic review and meta-analysis suggest that daily toothbrushing may be associated with significantly lower rates of HAP, particularly in patients receiving mechanical ventilation, lower rates of ICU mortality, shorter duration of mechanical ventilation, and shorter ICU length of stay. Policies and programs encouraging more widespread and consistent toothbrushing are warranted.
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Affiliation(s)
- Selina Ehrenzeller
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Eid MH, Ţânţu M–M, Latour JM, Sultan MA, Kandeel NA. Suction circuit flushing with chlorhexidine decreases ventilator-associated pneumonia: a quasi-experimental study. Front Med (Lausanne) 2023; 10:1295277. [PMID: 38111699 PMCID: PMC10725984 DOI: 10.3389/fmed.2023.1295277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/06/2023] [Indexed: 12/20/2023] Open
Abstract
Background Endotracheal suctioning of mechanically ventilated patients differs across the world. In many low and middle-income countries, endotracheal suctioning is often performed with a sterile suctioning catheter that is used for 12 h or during the length of one nursing shift. The effect of flushing multiple used endotracheal suction system with chlorhexidine after suctioning to reduce ventilator associated pneumonia (VAP) remains unclear. Aim The aim of the study is to assess the effectiveness of flushing multiple-used open endotracheal suction catheters and suctioning system with chlorhexidine gluconate 0.2% to reduce VAP in mechanically ventilated patients in a resource-limited Intensive Care Unit (ICU). Methods Due to the difficulty of blinding the intervention for nurses who perform endo-tracheal suction procedures, we adopted a quasi-experimental method with a randomized controlled trial design. A sample of 136 ICU patients were allocated to the intervention (n = 68) or control group (n = 68) between May and November 2020. The intervention was flushing the multiple-used suction catheter and suction system with 40ml chlorhexidine gluconate 0.2% and in the control group we used normal saline to flush the catheter and suction system. The primary outcome was incidence of VAP and the cost of the flushing solutions was the secondary outcome measure. Results Patients in the intervention group had a lower incidence of VAP compared to patients in the control group; 15 (22.1%) vs 29 (42.6%), p = 0.01. The incidence of late-onset VAP was 26.2% in the intervention group and 49% in the control group (p = 0.026) and the early-onset VAP was 13.2% in the intervention group and 25% in the control group (p = 0.081). Chlorhexidine gluconate 0.2% reduced the cost of suction system flushing (median: 78.4 vs 300 EGP, p < 0.001). Conclusion Using chlorhexidine gluconate 0.2% to flush multiple-used suctioning catheters after every endo-tracheal suction procedure might reduce the incidence of VAP in mechanically ventilated patients. Chlorhexidine gluconate 0.2% can be a cost-effective solution for flushing the suction circuit. Nurses working in resource-limited ICUs and using suctioning catheters multiple times might consider using chlorhexidine gluconate 0.2% instead of normal saline or distilled water when flushing the suction system. Clinical trial registration ClinicalTrials.gov, identifier NCT05206721.
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Affiliation(s)
- Mohamed H. Eid
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, United Kingdom
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Mansoura University, Mansoura, Egypt
| | - Monica – Marilena Ţânţu
- Medical Assistance and Physical Therapy Department, Faculty of Science, Physical Education and Informatics, University of Piteşti, Piteşti, Romania
| | - Jos M. Latour
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, United Kingdom
- Faculty of Nursing, Fudan University, Shanghai, China
| | - Mohammed Ahmed Sultan
- Anaesthesia and Intensive Care Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Nahed Attia Kandeel
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Mansoura University, Mansoura, Egypt
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Hurley J. Indirect (herd) effects of topical antibiotic prophylaxis and oral care versus non-antimicrobial methods increase mortality among ICU patients: realigning Cochrane review data to emulate a three-tier cluster randomised trial. BMJ Open 2023; 13:e064256. [PMID: 38035749 PMCID: PMC10689355 DOI: 10.1136/bmjopen-2022-064256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/19/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVE This study aimed to estimate the direct effects to recipients and indirect (herd) effects to non-recipients of each of topical antibiotic prophylaxis (TAP) and oral care methods on patient mortality within randomised concurrent controlled trials (RCCT) using Cochrane review data. DESIGN Control and intervention groups from 209 RCCTs of TAP (tier 3), oral care (tier 2) each versus non-antimicrobial (tier 1) ventilator-associated pneumonia (VAP) prevention interventions arranged to emulate a three-tiered cluster randomised trial (CRT). Eligible RCCTs were those including ICU patients with >50% of patients receiving >24 hours of mechanical ventilation (MV) with mortality data available as abstracted in 13 Cochrane reviews. EXPOSURES Direct and indirect exposures to either TAP or oral care within RCCTs versus non-antimicrobial VAP prevention interventions. MAIN OUTCOMES AND MEASURES The ICU mortality within control and intervention groups, respectively, within RCCTs of either TAP or oral care versus that within non-antimicrobial VAP prevention RCCTs serving as benchmark. RESULTS The ICU mortality was 23.9%, 23.0% and 20.3% for intervention groups and 28.7%, 25.5% and 19.5% for control groups of RCCTs of TAP (tier 1), oral care (tier 2) and non-antimicrobial (tier 3) methods of VAP prevention, respectively. In a random effects meta-regression including late mortality data and adjusting for group mean age, year of study publication and MV proportion, the direct effect of TAP and oral care versus non-antimicrobial methods were 1.04 (95% CI 0.78 to 1.30) and 1.1 (95% CI 0.77 to 1.43) whereas the indirect effects were 1.39 (95% CI 1.03 to 1.74) and 1.26 (95% CI 0.89 to 1.62), respectively. CONCLUSIONS Indirect (herd) effects from TAP and oral care methods on mortality are stronger than the direct effects as made apparent by the three-tiered CRT. These indirect effects, being harmful to concurrent control groups by increasing mortality, perversely inflate the appearance of benefit within RCCTs.
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Affiliation(s)
- James Hurley
- Melbourne Medical School, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
- Internal Medicine Service, Ballarat Health Services, Grampians Health, Ballarat, Victoria, Australia
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Martinez-Reviejo R, Tejada S, Jansson M, Ruiz-Spinelli A, Ramirez-Estrada S, Ege D, Vieceli T, Maertens B, Blot S, Rello J. Prevention of ventilator-associated pneumonia through care bundles: A systematic review and meta-analysis. JOURNAL OF INTENSIVE MEDICINE 2023; 3:352-364. [PMID: 38028633 PMCID: PMC10658042 DOI: 10.1016/j.jointm.2023.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/31/2023] [Accepted: 04/13/2023] [Indexed: 12/01/2023]
Abstract
Background Ventilator-associated pneumonia (VAP) represents a common hospital-acquired infection among mechanically ventilated patients. We summarized evidence concerning ventilator care bundles to prevent VAP. Methods A systematic review and meta-analysis were performed. Randomized controlled trials and controlled observational studies of adults undergoing mechanical ventilation (MV) for at least 48 h were considered for inclusion. Outcomes of interest were the number of VAP episodes, duration of MV, hospital and intensive care unit (ICU) length of stay, and mortality. A systematic search was conducted in the MEDLINE, the Cochrane Library, and the Web of Science between 1985 and 2022. Results are reported as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI). The PROSPERO registration number is CRD42022341780. Results Thirty-six studies including 116,873 MV participants met the inclusion criteria. A total of 84,031 participants underwent care bundles for VAP prevention. The most reported component of the ventilator bundle was head-of-bed elevation (n=83,146), followed by oral care (n=80,787). A reduction in the number of VAP episodes was observed among those receiving ventilator care bundles, compared with the non-care bundle group (OR=0.42, 95% CI: 0.33, 0.54). Additionally, the implementation of care bundles decreased the duration of MV (MD=-0.59, 95% CI: -1.03, -0.15) and hospital length of stay (MD=-1.24, 95% CI: -2.30, -0.18) in studies where educational activities were part of the bundle. Data regarding mortality were inconclusive. Conclusions The implementation of ventilator care bundles reduced the number of VAP episodes and the duration of MV in adult ICUs. Their application in combination with educational activities seemed to improve clinical outcomes.
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Affiliation(s)
- Raquel Martinez-Reviejo
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Sofia Tejada
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid 28029, Spain
- Clinical Research Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona 08035, Spain
| | - Miia Jansson
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, 90570, Finland
- RMIT University, Melbourne, 3010, Australia
| | - Alfonsina Ruiz-Spinelli
- Critical Care Department, Hospital de Clínicas Dr. Manuel Quintela, Montevideo, 11600, Uruguay
- Medicine Department, Universitat Internacional de Catalunya (UIC), Barcelona, 08017, Spain
| | | | - Duygu Ege
- Emergency Medicine Department, Adnan Menderes University, Aydin, 09010, Turkey
| | - Tarsila Vieceli
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, 90035-903, Brazil
| | - Bert Maertens
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, 9000, Belgium
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, 9000, Belgium
| | - Jordi Rello
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid 28029, Spain
- Clinical Research Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona 08035, Spain
- FOREVA Clinical Research, CHU Nimes, Université de Nîmes-Montpellier, Nîmes, 30012, France
- Medicine Department, Universitat Internacional de Catalunya (UIC), Barcelona, 08017, Spain
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Quinton K, Guy-Frank CJ, Syed S, Klugh JM, Dhanani NH, Adibi SS, Kao LS. Poor Oral Health in Trauma Intensive Care Unit Patients: Application of a Novel Oral Health Score. Surg Infect (Larchmt) 2023; 24:657-662. [PMID: 37695683 DOI: 10.1089/sur.2023.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
Background: Although oral hygiene in patients in the intensive care unit (ICU) has been shown to reduce hospital-associated infections, baseline and progressive oral health are often not reported because of lack of a standardized tool. The Oral Health Risk Assessment Value Index (OHRAVI) is a comprehensive oral assessment validated by dental providers. This study hypothesizes that non-dental providers can use OHRAVI in trauma ICU patients with minimal training and acceptable inter-rater reliability (IRR). Patients and Methods: Dentulous adult patients in the ICU at a level 1 trauma center were scored, excluding those with severe orofacial trauma. The eight categories of the OHRAVI were scored 0 to 3 (best to worst) with summed total and index (average) score. Index scores 1 or less need routine oral care; greater than 1-2 require moderate care; and greater than 2-3 require extensive oromaxillofacial care. Inter-rater reliability was assessed by two to three raters with Krippendorff's α (≥0.80 for good and ≥0.667 for acceptable). Results: Eighty-four ratings were completed across 34 patients, with 16 patients (47%) scored by all three raters. Ten patients (29%) had an index score <1. The average index score for patients was 1.28 (median, 1.34; range, 0.63-2). Krippendorff's α for index score was 0.86. For individual categories, α ranged from 0.44 to 1, with six of the eight categories achieving an α ≥ 0.667. Conclusions: With minimal training, non-dental providers were able to use OHRAVI with a good IRR for index score and an acceptable/good IRR for most individual categories. This novel, simple, comprehensive oral health score could help standardize oral assessment and facilitate future studies of peri-operative oral hygiene interventions.
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Affiliation(s)
- Kayli Quinton
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Chelsea J Guy-Frank
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Sophia Syed
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - James M Klugh
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Naila H Dhanani
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Shawn S Adibi
- UTHealth Houston, School of Dentistry, Houston, Texas, USA
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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12
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Parotto M, Gyöngyösi M, Howe K, Myatra SN, Ranzani O, Shankar-Hari M, Herridge MS. Post-acute sequelae of COVID-19: understanding and addressing the burden of multisystem manifestations. THE LANCET. RESPIRATORY MEDICINE 2023:S2213-2600(23)00239-4. [PMID: 37475125 DOI: 10.1016/s2213-2600(23)00239-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023]
Abstract
Individuals with SARS-CoV-2 infection can develop symptoms that persist well beyond the acute phase of COVID-19 or emerge after the acute phase, lasting for weeks or months after the initial acute illness. The post-acute sequelae of COVID-19, which include physical, cognitive, and mental health impairments, are known collectively as long COVID or post-COVID-19 condition. The substantial burden of this multisystem condition is felt at individual, health-care system, and socioeconomic levels, on an unprecedented scale. Survivors of COVID-19-related critical illness are at risk of the well known sequelae of acute respiratory distress syndrome, sepsis, and chronic critical illness, and these multidimensional morbidities might be difficult to differentiate from the specific effects of SARS-CoV-2 and COVID-19. We provide an overview of the manifestations of post-COVID-19 condition after critical illness in adults. We explore the effects on various organ systems, describe potential pathophysiological mechanisms, and consider the challenges of providing clinical care and support for survivors of critical illness with multisystem manifestations. Research is needed to reduce the incidence of post-acute sequelae of COVID-19-related critical illness and to optimise therapeutic and rehabilitative care and support for patients.
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Affiliation(s)
- Matteo Parotto
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada; Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, ON, Canada.
| | - Mariann Gyöngyösi
- Division of Cardiology, 2nd Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Kathryn Howe
- Division of Vascular Surgery, University Health Network, Toronto, ON, Canada
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Otavio Ranzani
- Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain; Pulmonary Division, Heart Institute, Faculty of Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Manu Shankar-Hari
- The Queen's Medical Research Institute, Edinburgh BioQuarter, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Margaret S Herridge
- Department of Medicine, University of Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
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13
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Kumpf O, Assenheimer M, Bloos F, Brauchle M, Braun JP, Brinkmann A, Czorlich P, Dame C, Dubb R, Gahn G, Greim CA, Gruber B, Habermehl H, Herting E, Kaltwasser A, Krotsetis S, Kruger B, Markewitz A, Marx G, Muhl E, Nydahl P, Pelz S, Sasse M, Schaller SJ, Schäfer A, Schürholz T, Ufelmann M, Waydhas C, Weimann J, Wildenauer R, Wöbker G, Wrigge H, Riessen R. Quality indicators in intensive care medicine for Germany - fourth edition 2022. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2023; 21:Doc10. [PMID: 37426886 PMCID: PMC10326525 DOI: 10.3205/000324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 07/11/2023]
Abstract
The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.
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Affiliation(s)
- Oliver Kumpf
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | | | - Frank Bloos
- Jena University Hospital, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
| | - Maria Brauchle
- Landeskrankenhaus Feldkirch, Department of Anesthesiology and Intensive Care Medicine, Feldkirch, Austria
| | - Jan-Peter Braun
- Martin-Luther-Krankenhaus, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Alexander Brinkmann
- Klinikum Heidenheim, Department of Anesthesia, Surgical Intensive Care Medicine and Special Pain Therapy, Heidenheim, Germany
| | - Patrick Czorlich
- University Medical Center Hamburg-Eppendorf, Department of Neurosurgery, Hamburg, Germany
| | - Christof Dame
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neonatology, Berlin, Germany
| | - Rolf Dubb
- Kreiskliniken Reutlingen, Academy of the District Hospitals Reutlingen, Germany
| | - Georg Gahn
- Städt. Klinikum Karlsruhe gGmbH, Department of Neurology, Karlsruhe, Germany
| | - Clemens-A. Greim
- Klinikum Fulda, Department of Anesthesia and Surgical Intensive Care Medicine, Fulda, Germany
| | - Bernd Gruber
- Niels Stensen Clinics, Marienhospital Osnabrueck, Department Hospital Hygiene, Osnabrueck, Germany
| | - Hilmar Habermehl
- Kreiskliniken Reutlingen, Klinikum am Steinenberg, Center for Intensive Care Medicine, Reutlingen, Germany
| | - Egbert Herting
- Universitätsklinikum Schleswig-Holstein, Department of Pediatrics and Adolescent Medicine, Campus Lübeck, Germany
| | - Arnold Kaltwasser
- Kreiskliniken Reutlingen, Academy of the District Hospitals Reutlingen, Germany
| | - Sabine Krotsetis
- Universitätsklinikum Schleswig-Holstein, Nursing Development and Nursing Science, affiliated with the Nursing Directorate Campus Lübeck, Germany
| | - Bastian Kruger
- Klinikum Heidenheim, Department of Anesthesia, Surgical Intensive Care Medicine and Special Pain Therapy, Heidenheim, Germany
| | | | - Gernot Marx
- University Hospital RWTH Aachen, Department of Intensive Care Medicine and Intermediate Care, Aachen, Germany
| | | | - Peter Nydahl
- Universitätsklinikum Schleswig-Holstein, Nursing Development and Nursing Science, affiliated with the Nursing Directorate Campus Kiel, Germany
| | - Sabrina Pelz
- Universitäts- und Rehabilitationskliniken Ulm, Intensive Care Unit, Ulm, Germany
| | - Michael Sasse
- Medizinische Hochschule Hannover, Department of Pediatric Cardiology and Pediatric Intensive Care Medicine, Hanover, Germany
| | - Stefan J. Schaller
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care Medicine, Munich, Germany
| | | | - Tobias Schürholz
- University Hospital RWTH Aachen, Department of Intensive Care Medicine and Intermediate Care, Aachen, Germany
| | - Marina Ufelmann
- Technical University of Munich, Klinikum rechts der Isar, Department of Nursing, Munich, Germany
| | - Christian Waydhas
- Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Surgical University Hospital and Polyclinic, Bochum, Germany
- Medical Department of the University of Duisburg-Essen, Essen, Germany
| | - Jörg Weimann
- Sankt-Gertrauden Krankenhaus, Department of Anesthesia and Interdisciplinary Intensive Care Medicine, Berlin, Germany
| | | | - Gabriele Wöbker
- Helios Universitätsklinikum Wuppertal, Universität Witten-Herdecke, Department of Intensive Care Medicine, Wuppertal, Germany
| | - Hermann Wrigge
- Bergmannstrost Hospital Halle, Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Halle, Germany
- Martin-Luther University Halle-Wittenberg, Medical Faculty, Halle, Germany
| | - Reimer Riessen
- Universitätsklinikum Tübingen, Department of Internal Medicine, Medical Intensive Care Unit, Tübingen, Germany
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14
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Quinn B. Best Practices in Oral Care. Crit Care Nurse 2023; 43:64-67. [PMID: 37257868 PMCID: PMC10443897 DOI: 10.4037/ccn2023507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Topic Assessing functional cognition is a critical need for intensive care unit survivors transitioning to another level of care. Clinical Relevance Up to 62% of patients discharged from an intensive care unit have significant cognitive impairment that is not associated with severity of illness, number of comorbidities, or length of hospital stay. For more than 20 years, researchers have published an array of potentially effective interventions, including case management, patient and informal caregiver education, and home health care services. Purpose To describe the impact of and potential interventions for cognitive decline at intensive care unit discharge and discharge readiness on 30-day readmission rates. Content Covered Assessing the patient’s functional cognition assessment and advocating for appropriate resources are needed to improve patient and clinical outcomes.
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Affiliation(s)
- Barbara Quinn
- Barbara Quinn is a nurse consultant with 30 years of experience, most recently the Director of Professional Practice and Nursing Excellence at Sutter Health in the Office of the Chief Nurse Officer
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15
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Hurley JC. Establishing the safety of selective digestive decontamination within the ICU population: a bridge too far? Trials 2023; 24:337. [PMID: 37198636 DOI: 10.1186/s13063-023-07356-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/21/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Infection prevention interventions within the intensive care unit (ICU) setting, whether studied within quality improvement projects or cluster randomized trials (CRT), are seen as low risk and grounded in an ethical imperative. Selective digestive decontamination (SDD) appears highly effective at preventing ICU infections within randomized concurrent control trials (RCCTs) prompting mega-CRTs with mortality as the primary endpoint. FINDINGS Surprisingly, the summary results of RCCTs versus CRTs differ strikingly, being respectively, a 15-percentage-point versus a zero-percentage-point ICU mortality difference between control versus SDD intervention groups. Multiple other discrepancies are equally puzzling and contrary to both prior expectations and the experience within population-based studies of infection prevention interventions using vaccines. Could spillover effects from SDD conflate the RCCT control group event rate differences and represent population harm? Evidence that SDD is fundamentally safe to concurrent non-recipients in ICU populations is absent. A postulated CRT to realize this, the SDD Herd Effects Estimation Trial (SHEET), would require > 100 ICUs to achieve sufficient statistical power to find a two-percentage-point mortality spillover effect. Moreover, as a potentially harmful population-based intervention, SHEET would pose novel and insurmountable ethical issues including who is the research subject; whether informed consent is required and from whom; whether there is equipoise; the benefit versus the risk; considerations of vulnerable groups; and who should be the gatekeeper? CONCLUSION The basis for the mortality difference between control and intervention groups of SDD studies remains unclear. Several paradoxical results are consistent with a spillover effect that would conflate the inference of benefit originating from RCCTs. Moreover, this spillover effect would constitute to herd peril.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.
- Division of Internal Medicine, Grampians Health Services, Ballarat, VIC, Australia.
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16
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Roquilly A, Francois B, Huet O, Launey Y, Lasocki S, Weiss E, Petrier M, Hourmant Y, Bouras M, Lakhal K, Le Bel C, Flattres Duchaussoy D, Fernández-Barat L, Ceccato A, Flet L, Jobert A, Poschmann J, Sebille V, Feuillet F, Koulenti D, Torres A. Interferon gamma-1b for the prevention of hospital-acquired pneumonia in critically ill patients: a phase 2, placebo-controlled randomized clinical trial. Intensive Care Med 2023; 49:530-544. [PMID: 37072597 PMCID: PMC10112824 DOI: 10.1007/s00134-023-07065-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/31/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE We aimed to determine whether interferon gamma-1b prevents hospital-acquired pneumonia in mechanically ventilated patients. METHODS In a multicenter, placebo-controlled, randomized trial conducted in 11 European hospitals, we randomly assigned critically ill adults, with one or more acute organ failures, under mechanical ventilation to receive interferon gamma-1b (100 µg every 48 h from day 1 to 9) or placebo (following the same regimen). The primary outcome was a composite of hospital-acquired pneumonia or all-cause mortality on day 28. The planned sample size was 200 with interim safety analyses after enrolling 50 and 100 patients. RESULTS The study was discontinued after the second safety analysis for potential harm with interferon gamma-1b, and the follow-up was completed in June 2022. Among 109 randomized patients (median age, 57 (41-66) years; 37 (33.9%) women; all included in France), 108 (99%) completed the trial. Twenty-eight days after inclusion, 26 of 55 participants (47.3%) in the interferon-gamma group and 16 of 53 (30.2%) in the placebo group had hospital-acquired pneumonia or died (adjusted hazard ratio (HR) 1.76, 95% confidence interval (CI) 0.94-3.29; P = 0.08). Serious adverse events were reported in 24 of 55 participants (43.6%) in the interferon-gamma group and 17 of 54 (31.5%) in the placebo group (P = 0.19). In an exploratory analysis, we found that hospital-acquired pneumonia developed in a subgroup of patients with decreased CCL17 response to interferon-gamma treatment. CONCLUSIONS Among mechanically ventilated patients with acute organ failure, treatment with interferon gamma-1b compared with placebo did not significantly reduce the incidence of hospital-acquired pneumonia or death on day 28. Furthermore, the trial was discontinued early due to safety concerns about interferon gamma-1b treatment.
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Affiliation(s)
- Antoine Roquilly
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France.
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France.
| | - Bruno Francois
- ICU Department and Inserm CIC 1435 & UMR 1092, University Hospital of Limoges, Limoges, France
| | - Olivier Huet
- Département d'anesthésie réanimation et medecine peri-operatoire, CHRU de Brest, Université de Bretagne Occidentale, 29000, Brest, France
| | - Yoann Launey
- Department of Anaesthesia, Critical Care and Perioperative Medicine, Univ Rennes, CHU Rennes, 35000, Rennes, France
| | - Sigismond Lasocki
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Angers, 49000, Angers, France
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Université Paris Cité, INSERM UMR_S1149, and AP-HP Nord, Hôpital Beaujon, Clichy, France
| | - Melanie Petrier
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France
| | - Yannick Hourmant
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France
| | - Marwan Bouras
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France
| | - Karim Lakhal
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France
| | - Cecilia Le Bel
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France
| | | | - Laia Fernández-Barat
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Servei de Pneumologia, Hospital Clinic, Barcelona, Universitat de Barcelona, CIBERES, Icrea, IDIBAPS, Barcelona, Spain
| | - Adrian Ceccato
- Servei de Pneumologia, Hospital Clinic, Barcelona, Universitat de Barcelona, CIBERES, Icrea, IDIBAPS, Barcelona, Spain
| | - Laurent Flet
- Nantes Université, CHU Nantes, Pharmacie, 44000, Nantes, France
| | - Alexandra Jobert
- Nantes Université, CHU Nantes, DRI, Département promotion, cellule vigilances recherche, Nantes, France
- Nantes Université, Université de Tours, CHU Nantes, CHU Tours, INSERM, SPHERE U1246, 44000, Nantes, France
| | - Jeremie Poschmann
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France
| | - Veronique Sebille
- Nantes Université, CHU Nantes, DRI, Plateforme de Méthodologie et de Biostatistique, 44000, Nantes, France
- Nantes Université, Université de Tours, CHU Nantes, CHU Tours, INSERM, SPHERE U1246, 44000, Nantes, France
| | - Fanny Feuillet
- Nantes Université, CHU Nantes, DRI, Plateforme de Méthodologie et de Biostatistique, 44000, Nantes, France
- Nantes Université, Université de Tours, CHU Nantes, CHU Tours, INSERM, SPHERE U1246, 44000, Nantes, France
| | - Despoina Koulenti
- 2nd Critical Care Department, Attikon University Hospital, Athens, Greece
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Antoni Torres
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Effect of an educational intervention on compliance with care bundle items to prevent ventilator-associated pneumonia. Intensive Crit Care Nurs 2023; 75:103342. [PMID: 36464606 DOI: 10.1016/j.iccn.2022.103342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 12/03/2022]
Abstract
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.
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18
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Jahanshir M, Nobahar M, Ghorbani R, Malek F. Effect of clove mouthwash on the incidence of ventilator-associated pneumonia in intensive care unit patients: a comparative randomized triple-blind clinical trial. Clin Oral Investig 2023:10.1007/s00784-023-04972-w. [PMID: 36961592 PMCID: PMC10036978 DOI: 10.1007/s00784-023-04972-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/19/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVES Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in intensive care units (ICUs), and the use of mouthwash is the most widely used method to prevent its incidence. The aim of this study was to investigate effect of clove mouthwash on the incidence of VAP in the ICU. MATERIALS AND METHODS This comparative, randomized, triple-blind, clinical trial was conducted on 168 eligible ICU patients at Kosar Hospital in Semnan, Iran, during 2021-2022, who were divided into intervention and control groups using random blocks. The intervention group received clove extract mouthwash at 6.66% concentration, and the control group received chlorhexidine 0.2% twice a day for 5 days (routine care). Data were collected using a demographic questionnaire, and disease severity was measured based on the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, oral health status was examined using the Beck Oral Assessment Scale (BOAS), and VAP diagnosis was made based on the Modified Clinical Pulmonary Infection Score (MCPIS). RESULTS Before the intervention, there was no significant difference in disease severity (p = 0.412) and oral health status (p = 0.239) between the patients in the two groups. After the intervention, 20.2% of the patients in the intervention group and 41.7% of those in the control group acquired VAP. The risk of VAP was 2.06 times higher in the control group than in the intervention group (p = 0.005, 95% CI: 1.26-3.37, RR = 2.06), but the severity of VAP did not differ significantly between the patients in the two groups (p = 0.557). CONCLUSION The findings showed that clove mouthwash reduces the incidence of VAP significantly. CLINICAL RELEVANCE Clove mouthwash can be used as a simple and low-cost method to prevent VAP in ICU patients.
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Affiliation(s)
- Mojgan Jahanshir
- Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran
| | - Monir Nobahar
- Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran.
- Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran.
- Department of Nursing, Faculty of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Postal Code: 3513138111, Iran.
| | - Raheb Ghorbani
- Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Farhad Malek
- Department of Internal Medicine, Kosar Hospital, Semnan University of Medical Sciences, Semnan, Iran
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19
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Iwona GM, Anna P, Mateusz F, Michal K, Anna K, Paweł M, Estera JM, Dorota R, Agnieszka C, Barbara Ż, Jadwiga WM. Impact of tooth brushing on oral bacteriota and health care-associated infections among ventilated COVID-19 patients: an intervention study. Antimicrob Resist Infect Control 2023; 12:17. [PMID: 36890608 PMCID: PMC9992909 DOI: 10.1186/s13756-023-01218-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/15/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Up to 48% of ventilated coronavirus disease 2019 (COVID-19) patients develop ventilator-associated pneumonia (VAP) during hospitalization in an ICU. Dysbiotic oral microbiota can colonize the lower respiratory tract and lead to VAP. It is recommended to introduce oral care strategies in the ICU to prevent VAP. In this study, we observed the impact of an oral hygienic protocol with tooth brushing on cultivable oral bacteriota, the incidence of HAI and patient safety among mechanically ventilated COVID-19 patients in an ICU setting. METHODS In this prospective cohort study, we recruited 56 adult COVID-19 patients who qualified for mechanical ventilation. Patients were divided into 2 groups depending on the oral care procedure: standard and extended oral procedures with tooth brushing. Oral bacteriota samples were taken first within 36 h and after 7 days of intubation. Microorganisms were identified by MALDI/TOF mass spectrometry. bacterial health care-associated infection (HAI) cases were retrospectively analyzed by etiology. A PFGE study was performed for Klebsiella pneumoniae to check for clonal spreading of strains from oral bacteriota samples and HAI cases. RESULTS We observed significant dysbiosis and a decrease in cultivable oral bacteriota diversity, with a high frequency of potentially pathogenic species, including Acinetobacter baumannii and K. pneumoniae. The HAI incidence rate was high (55.2/1000 patient-days), most commonly of K. pneumoniae and A. baumannii etiologies, which correlated with the presence of A. baumannii and K. pneumoniae in the oral samples. Strains isolated from VAP cases were the same as oral isolates in 8 cases. The procedure with tooth brushing led to less frequent identification of A. baumannii in oral samples (55.6% vs. 5.3%, p = 0.001); however, it did not decrease the incidence of HAIs. CONCLUSIONS Dysbiotic oral bacteriota is an important source of respiratory pathogens. The introduction of tooth brushing in oral hygiene protocols in an ICU setting was effective in decreasing the extent of oral bacteriota dysbiosis; however, it did not reduce the risk of HAIs or mortality. TRIAL REGISTRATION 1072.6120.333.2020.
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Affiliation(s)
- Gregorczyk-Maga Iwona
- Institute of Dentistry, Faculty of Medicine, Jagiellonian University Medical College, Ul. Montelupich 4, 31-155, Kraków, Poland
| | - Pałka Anna
- Microbiology Unit, University Hospital, Ul. Jakubowskiego 2, 30-688, Kraków, Poland
| | - Fiema Mateusz
- Department of Endocrinology, University Hospital, Ul. Jakubowskiego 2, 30-688, Kraków, Poland
| | - Kania Michal
- Doctoral School of Medicine and Health Sciences, Jagiellonian University Medical College, Ul. św. Anny 12, 31-008, Kraków, Poland. .,Chair of Metabolic Diseases, Faculty of Medicine, Jagiellonian University Medical College, Ul. Jakubowskiego 2, 30-688, Kraków, Poland.
| | - Kujawska Anna
- Microbiology Unit, University Hospital, Ul. Jakubowskiego 2, 30-688, Kraków, Poland
| | - Maga Paweł
- Chair of Angiology, Faculty of Medicine, Jagiellonian University Medical College, Ul. Jakubowskiego 2, 30-688, Kraków, Poland
| | - Jachowicz-Matczak Estera
- Chair of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Czysta 18, 31-121, Kraków, Poland
| | - Romaniszyn Dorota
- Chair of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Czysta 18, 31-121, Kraków, Poland
| | - Chmielarczyk Agnieszka
- Chair of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Czysta 18, 31-121, Kraków, Poland
| | - Żółtowska Barbara
- Center for Innovative Therapy, Clinical Research Coordination Center, University Hospital, Ul. Jakubowskiego 2, 30-688, Kraków, Poland
| | - Wójkowska-Mach Jadwiga
- Chair of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Czysta 18, 31-121, Kraków, Poland
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20
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Blot S, Conoscenti E. Why to monitor adherence to oral care protocols in intensive care units? Aust Crit Care 2023; 36:169-170. [PMID: 34980521 DOI: 10.1016/j.aucc.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/05/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Burns, Trauma and Critical Care Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Elena Conoscenti
- Infectious Disease and Infection Control Service, ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
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21
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Krüger L, Hauß A, Oldag A, Ritter S, Schulz T, Vogt S, Wefer F. [Treatment algorithm: oral hygiene in orally intubated patients]. Med Klin Intensivmed Notfmed 2023; 118:122-124. [PMID: 36112156 DOI: 10.1007/s00063-022-00954-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Lars Krüger
- Arbeitskreis Evidence-based Nursing (AK EBN), Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland.
- Stabsstelle Projekt- und Wissensmanagement/Pflegeentwicklung Intensivpflege, Pflegedirektion, Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Georgstraße 11, 32345, Bad Oeynhausen, Deutschland.
| | - Armin Hauß
- Geschäftsbereich Pflege - Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Anne Oldag
- Arbeitskreis Evidence-based Nursing (AK EBN), Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
| | - Sandra Ritter
- Klinik für Neurologie mit Experimenteller Neurologie, Pflegedienst (Intensivstation), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Tijana Schulz
- Klinik für Neurologie mit Experimenteller Neurologie, Pflegedienst (Intensivstation), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Sarah Vogt
- Arbeitskreis Evidence-based Nursing (AK EBN), Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
| | - Franziska Wefer
- Arbeitskreis Evidence-based Nursing (AK EBN), Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
- Stabsstelle Pflegeentwicklung, Pflegedirektion, Herz- und Diabeteszentrum NRW, Universitätsklinikum der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
- Institut für Pflegewissenschaft, Medizinische Fakultät und Universitätsklinik Köln, Universität zu Köln, Köln, Deutschland
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22
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Thapa D, Liu T, Chair SY. 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. Intensive Crit Care Nurs 2023; 74:103310. [PMID: 36154789 DOI: 10.1016/j.iccn.2022.103310] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Dejina Thapa
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region.
| | - Ting Liu
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region.
| | - Sek Ying Chair
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region.
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23
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Narbutaitė J, Skirbutytė G, Virtanen JI. Oral care in intensive care units: Lithuanian nurses' attitudes and practices. Acta Odontol Scand 2023:1-6. [PMID: 36597772 DOI: 10.1080/00016357.2022.2163285] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Julija Narbutaitė
- Faculty of Odontology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Gertrūda Skirbutytė
- Faculty of Odontology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jorma I Virtanen
- Faculty of Medicine, University of Bergen, Bergen, Norway.,Institute of Dentistry, University of Turku, Finland
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24
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Reduce the risk of ventilator-associated pneumonia in ICU patients by Ozonated water mouthwash: a double-blind randomized clinical trial. Am J Infect Control 2022:S0196-6553(22)00789-1. [DOI: 10.1016/j.ajic.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/13/2022]
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25
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Bourgault AM, Xie R, Talbert S, Sole ML. Association of enteral feeding with microaspiration in critically ill adults. Appl Nurs Res 2022; 67:151611. [DOI: 10.1016/j.apnr.2022.151611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 05/25/2022] [Accepted: 06/27/2022] [Indexed: 10/17/2022]
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26
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Omar AS, Kaddoura R. De-adoption of oral chlorhexidine for mechanically ventilated patients: get thee to a conclusion. Acute Crit Care 2022; 37:480-481. [PMID: 35977892 PMCID: PMC9475164 DOI: 10.4266/acc.2022.00556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/26/2022] [Indexed: 12/03/2022] Open
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27
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Fanning J, Panigada M, Li Bassi G. Nosocomial Pneumonia in the Mechanically Ventilated Patient. Semin Respir Crit Care Med 2022; 43:426-439. [PMID: 35714627 DOI: 10.1055/s-0042-1749448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a common complication occurring in critically ill patients who are mechanically ventilated and is the leading cause of nosocomial infection-related death. Etiologic agents for VAP widely differ based on the population of intensive care unit patients, duration of hospital stay, and prior antimicrobial therapy. VAP due to multidrug-resistant pathogens is associated with the highest morbidity and mortality, likely due to delays in appropriate antimicrobial treatment. International guidelines are currently available to guide diagnostic and therapeutic strategies. VAP can be prevented through various pharmacological and non-pharmacological interventions, which are more effective when grouped as bundles. When VAP is clinically suspected, diagnostic strategies should include early collection of respiratory samples to guide antimicrobial therapy. Empirical treatment should be based on the most likely etiologic microorganisms and antibiotics likely to be active against these microorganisms. Response to therapy should be reassessed after 3 to 5 days and antimicrobials adjusted or de-escalated to reduce the burden of the disease. Finally, considering that drug resistance is increasing worldwide, several novel antibiotics are being tested to efficiently treat VAP in the coming decades.
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Affiliation(s)
- Jonathon Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, Royal Brisbane and Women's Hospital, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Nuffield Department of Population Health, Oxford University, United Kingdom
| | - Mauro Panigada
- Department of Anaesthesiology, Intensive Care and EmergencyFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Queensland University of Technology, Brisbane, Australia.,Intensive Care Unit, The Wesley Hospital, Auchenflower, Queensland, Australia.,Wesley Medical Research, The Wesley Hospital, Auchenflower, Australia
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28
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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29
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Honore PM, Afonso EDP, Blot S. Dental care and hospital mortality in ICU patients. Am J Infect Control 2022; 50:714-715. [PMID: 35623669 DOI: 10.1016/j.ajic.2022.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 02/15/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Patrick M Honore
- Intensive Care Unit Department, Faculty of Medicine of the Université Libre de Bruxelles, Brugmann University Hospital, Brussels, Belgium
| | - Elsa da Palma Afonso
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Senior Lecturer, School of Nursing and Midwifery, Anglia Ruskin University, Cambridge, UK
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium.
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30
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Blot S, Ruppé E, Harbarth S, Asehnoune K, Poulakou G, Luyt CE, Rello J, Klompas M, Depuydt P, Eckmann C, Martin-Loeches I, Povoa P, Bouadma L, Timsit JF, Zahar JR. Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies. Intensive Crit Care Nurs 2022; 70:103227. [PMID: 35249794 PMCID: PMC8892223 DOI: 10.1016/j.iccn.2022.103227] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Stijn Blot
- Dept. of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium.
| | - Etienne Ruppé
- INSERM, IAME UMR 1137, University of Paris, France; Department of Bacteriology, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Stephan Harbarth
- Infection Control Program, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Karim Asehnoune
- Department of Anesthesiology and Surgical Intensive Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France
| | - Garyphalia Poulakou
- 3(rd) Department of Medicine, National and Kapodistrian University of Athens, Medical School, Sotiria General Hospital of Athens, Greece
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Jordi Rello
- Vall d'Hebron Institut of Research (VHIR) and Centro de Investigacion Biomedica en Red de Enferemedades Respiratorias (CIBERES), Instituto Salud Carlos III, Barcelona, Spain
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, United States; Department of Medicine, Brigham and Women's Hospital, Boston, United States
| | - Pieter Depuydt
- Intensive Care Department, Ghent University Hospital, Gent, Belgium
| | - Christian Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Medical University Hannover, Germany
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland; Hospital Clinic, Universidad de Barcelona, CIBERes, Barcelona, Spain
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, CHLO, Lisbon, Portugal; NOVA Medical School, Comprehensive Health Research Center, CHRC, New University of Lisbon, Lisbon Portugal; Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Lila Bouadma
- INSERM, IAME UMR 1137, University of Paris, France; Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jean-Francois Timsit
- INSERM, IAME UMR 1137, University of Paris, France; Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jean-Ralph Zahar
- INSERM, IAME UMR 1137, University of Paris, France; Microbiology, Infection Control Unit, GH Paris Seine Saint-Denis, APHP, Bobigny, France
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31
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Li HY, Wang HS, Wang YL, Wang J, Huo XC, Zhao Q. Management of Ventilator-Associated Pneumonia: Quality Assessment of Clinical Practice Guidelines and Variations in Recommendations on Drug Therapy for Prevention and Treatment. Front Pharmacol 2022; 13:903378. [PMID: 35668946 PMCID: PMC9163435 DOI: 10.3389/fphar.2022.903378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/29/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose: To assess the quality of clinical practice guidelines (CPGs) related to drug therapy for prevention and control of ventilator-associated pneumonia (VAP) and compare the differences and similarities between recommendations. Methods: Electronic databases (including PubMed, Cochrane library, Embase, Web of Science), guideline development organizations, and professional societies were searched to identify CPGs for VAP from 20 January 2012 to 20 January 2022. The Appraisal of Guidelines Research & Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. The recommendations on drug therapy for prevention and treatment for each guideline were extracted, and then a descriptive synthesis was performed to analyze the scope/topic, and consistency of the recommendations. Results: Thirteen CPGs were included. The median score and interquartile range (IQR) in each domain are shown below: scope and purpose 72.22% (63.89%,83.33%); stakeholder involvement 44.44% (38.89%,52.78%); rigor of development 43.75% (31.25%,57.29%); clarity and presentation 94.44% (77.78%,94.44%); applicability 20.83 (8.34%,33.34%) and editorial independence 50% (33.33%,66.67%). We extracted 21 recommendations on drug therapy for prevention of VAP and 51 recommendations on drugs used for treatment. Some controversies remained among the included guidelines. Conclusion: There is considerable variability in the development processes and reporting of VAP guidelines. Despite many similarities, the recommendations still had some inconsistencies in the details. For the prevention and treatment of VAP, local microbial epidemiology and antibiotic sensitivity must be considered, and recommendations should be regularly revised as new evidence emerges.
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Affiliation(s)
- Hong-Yan Li
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Hai-Shan Wang
- Department of Intensive Care Unit, Yantai YEDA Hospital, Yantai, China
| | - Ying-Lin Wang
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Jing Wang
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Xue-Chen Huo
- Department of Hepatobiliary Surgery, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
- *Correspondence: Xue-Chen Huo, ; Quan Zhao,
| | - Quan Zhao
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
- *Correspondence: Xue-Chen Huo, ; Quan Zhao,
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32
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Dale C, Cuthbertson B. De-adoption of chlorhexidine oral care and ICU mortality. Authors' reply. Intensive Care Med 2022; 48:626-627. [PMID: 35174399 DOI: 10.1007/s00134-022-06649-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Craig Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, #130-155 College Street, Toronto, ON, M5T1P8, Canada.
- Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Canada.
- University of Toronto Centre for the Study of Pain, Toronto, Canada.
- Sunnybrook Research Institute, Toronto, Canada.
- Interdepartmental Division of Critical Care, Department of Medicine, Surgery, Anaesthesia and Paediatrics, Li Ka Shing Knowledge Institute, 204 Victoria Street, 4th Floor, Room 411, Toronto, ON, M5B 1T8, Canada.
| | - Brian Cuthbertson
- Sunnybrook Research Institute, Toronto, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, Surgery, Anaesthesia and Paediatrics, Li Ka Shing Knowledge Institute, 204 Victoria Street, 4th Floor, Room 411, Toronto, ON, M5B 1T8, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, D108 - 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
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Oral Care in Intensive Care Unit and Chlorhexidine: An Endless Story. Dimens Crit Care Nurs 2022; 41:115-117. [PMID: 35099159 DOI: 10.1097/dcc.0000000000000516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Klompas M. New Insights into the Prevention of Hospital-Acquired Pneumonia/Ventilator-Associated Pneumonia Caused by Viruses. Semin Respir Crit Care Med 2022; 43:295-303. [PMID: 35042261 DOI: 10.1055/s-0041-1740582] [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
A fifth or more of hospital-acquired pneumonias may be attributable to respiratory viruses. The SARS-CoV-2 pandemic has clearly demonstrated the potential morbidity and mortality of respiratory viruses and the constant threat of nosocomial transmission and hospital-based clusters. Data from before the pandemic suggest the same can be true of influenza, respiratory syncytial virus, and other respiratory viruses. The pandemic has also helped clarify the primary mechanisms and risk factors for viral transmission. Respiratory viruses are primarily transmitted by respiratory aerosols that are routinely emitted when people exhale, talk, and cough. Labored breathing and coughing increase aerosol generation to a much greater extent than intubation, extubation, positive pressure ventilation, and other so-called aerosol-generating procedures. Transmission risk is proportional to the amount of viral exposure. Most transmissions take place over short distances because respiratory emissions are densest immediately adjacent to the source but then rapidly dilute and diffuse with distance leading to less viral exposure. The primary risk factors for transmission then are high viral loads, proximity, sustained exposure, and poor ventilation as these all increase net viral exposure. Poor ventilation increases the risk of long-distance transmission by allowing aerosol-borne viruses to accumulate over time leading to higher levels of exposure throughout an enclosed space. Surgical and procedural masks reduce viral exposure but do not eradicate it and thus lower but do not eliminate transmission risk. Most hospital-based clusters have been attributed to delayed diagnoses, transmission between roommates, and staff-to-patient infections. Strategies to prevent nosocomial respiratory viral infections include testing all patients upon admission, preventing healthcare providers from working while sick, assuring adequate ventilation, universal masking, and vaccinating both patients and healthcare workers.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Blot S, Deschepper M, Labeau S. De-adoption of chlorhexidine oral care and ICU mortality. Intensive Care Med 2022; 48:624-625. [PMID: 35037992 DOI: 10.1007/s00134-022-06621-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Campus UZ Gent, Corneel Heymanslaan 10, 9000, Ghent, Belgium. .,Burns, Trauma and Critical Care Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Mieke Deschepper
- Strategic Policy Cell, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Sonia Labeau
- School of Healthcare, Nurse Education Programme, HOGENT University of Applied Sciences and Arts, Ghent, Belgium
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Blot S, Labeau SO, Dale CM. Why it’s time to abandon antiseptic mouthwashes. Intensive Crit Care Nurs 2022; 70:103196. [DOI: 10.1016/j.iccn.2022.103196] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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