A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions

Effect of perioperative oral management on postoperative bloodstream infection in heart valve surgery patients

OBJECTIVE

There is a well-known relationship between oral hygiene and infective endocarditis. Epidemiological evidence regarding perioperative oral management (POM) for cancer surgery has been accumulated, but this evidence is not sufficient for cardiac surgery. Therefore, our purpose was to investigate whether POM can prevent postoperative complications in patients undergoing heart valve surgery.

SUBJECTS AND METHODS

Using single-arm medical information, we retrospectively enrolled 301 patients who underwent heart valve surgery between April 2010 and March 2019. The patient background was adjusted by the propensity score (PS). We then analyzed the impact of POM on postoperative bloodstream infection (PBSI), postoperative pneumonia, and mortality using PS inverse probability of treatment weighting (IPTW).

RESULTS

IPTW revealed that the POM group had a lower incidence of PBSI than the control group, with an odds ratio of 0.316 (p = 0.003). The mortality in the POM group was significantly lower than that in the control group (p = 0.023). Fourteen patients died in the present study and 6 of them were infection-related.

CONCLUSIONS

POM was significantly associated with decreased incidence of PBSI and mortality. The results suggest that POM is beneficial for the prevention of PBSI and mortality in patients undergoing heart valve surgery.

British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units

BACKGROUND

Patients who are critically ill are at increased risk of hospital acquired pneumonia and ventilator associated pneumonia. Effective evidence based oral care may reduce the incidence of such iatrogenic infection.

AIM

To provide an evidence-based British Association of Critical Care Nurses endorsed consensus paper for best practice relating to implementing oral care, with the intention of promoting patient comfort and reducing hospital acquired pneumonia and ventilator associated pneumonia in critically ill patients.

DESIGN

A nominal group technique was adopted. A consensus committee of adult critical care nursing experts from the United Kingdom met in 2018 to evaluate and review the literature relating to oral care, its application in reducing pneumonia in critically ill adults and to make recommendations for practice. An elected national board member for the British Association of Critical Care Nurses chaired the round table discussion.

METHODS

The committee focused on 5 aspects of oral care practice relating to critically ill adult patients. The evidence was evaluated for each practice within the context of reducing pneumonia in the mechanically ventilated patient or pneumonia in the non-ventilated patient. The five practices included the frequency for oral care; tools for oral care; oral care technique; solutions used and oral care in the non-ventilated patient who is critically ill and is at risk of aspiration. The group searched the best available evidence and evaluated this using the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence from high to very low, and to formulate recommendations as strong, moderate, weak, or best practice consensus statement when applicable.

RESULTS

The consensus group generated recommendations, delineating an approach to best practice for oral care in critically ill adult patients. Recommendations included guidance for frequency and procedure for oral assessment, toothbrushing, and moisturising the mouth. Evidence on the use of chlorhexidine is not consistent and caution is advised with its routine use.

CONCLUSION

Oral care is an important part of the care of critically ill patients, both ventilated and non-ventilated. An effective oral care programme reduces the incidence of pneumonia and promotes patient comfort.

RELEVANCE TO CLINICAL PRACTICE

Effective oral care is integral to safe patient care in critical care.

The impact of tooth brushing versus tooth brushing and chlorhexidine application to avoid postoperative pneumonia in children

BACKGROUND

The pathogenesis of postsurgical pneumonia is a complicated and multifactorial process, in which elements like oral bacteria, orotracheal intubation, and dental hygiene play an important role. The objective of this study was to evaluate the efficacy of 2 types of oral hygiene interventions in decreasing cases of postsurgical pneumonia.

METHODS

In pediatric patients scheduled for surgery, a quasi-experimental study was carried out over a 2-year period to evaluate the efficacy of 2 types of oral hygiene interventions. There were 2 groups of intervention with 1 group for comparison. Intervention groups were tooth brushing by a dentist (intervention group 1) and dental brushing by parents + chlorhexidine gluconate (intervention group 2). Data from the year with no oral hygiene interventions were used as the baseline group.

RESULTS

A total of 2,535 surgical procedures were followed. Baseline group incidence of postoperative pneumonia was 10 per 1,000 surgeries, 0.2 per 1,000 surgeries in the intervention group 1 (P = .04), and 0.8 per 1,000 surgeries in the intervention group 2. Intervention group 1 was protective against postoperative pneumonia (odds ratio, 0.06; P = .02; 95% confidence interval, 0.033-0.079), but there was no benefit with intervention group 2 (odds ratio, 0.87; P = .599; 95% confidence interval, 0.52-1.46).

CONCLUSIONS

Dental brushing performed before surgery by a pediatric dentist was effective in reducing the incidence of postoperative pneumonia in pediatric patients.

Analysis of the Preventative Influence of an Oral Hygiene Protocol on Ventilator-Associated Pneumonia

AbstractVentilator-associated pneumonia (VAP) is the most commonly reported nosocomial infection among intensive care unit (ICU) patients. This study aimed to evaluate the influence of an oral hygiene protocol on VAP incidence among mechanically-ventilated (MV) ICU patients. The dentate patients admitted without VAP to the hospital’s adult ICU requiring mechanical ventilation for ≥48 hours during a 4-month period in two consecutive years (2015 – Control group and 2016 – Experimental group) were included in this investigation. The oral hygiene protocol was implemented daily, once a day, in the morning hours, using a disposable brush with suction and ultrasoft bristles and 3 g of 0.12% chlorhexidine gel. Hospital-related respiratory infection data, including VAP diagnoses and microbiological analyses, were collected from the monthly health epidemiological notification bulletins issued by the hospital. T tests were applied to compare variables before versus after implementation of the oral hygiene protocol with a significance criterion of P < .05. 43.94% reduction in VAP rate after the protocol implementation was observed. Implementation of the protocol was associated with a significant reduction of Enterobacter spp infections and no cases of VAP related to the main etiological agents of the disease (i.e., S. aureus and C. albicans) were identified. It can be concluded that an oral hygiene protocol performed with a suction brush and 0.12% chlorhexidine gel can serve as an effective prophylaxis against VAP in patients under mechanical ventilation.Keywords: Intensive Care Units. Disease Prevention. Oral Hygiene.ResumoA pneumonia associada à ventilação (PAV) é a infecção nosocomial mais comumente relatada em pacientes de Unidade de Terapia Intensiva (UTI). Este estudo teve como objetivo avaliar a influência de um protocolo de higiene bucal na incidência de PAV entre pacientes sob ventilação mecânica (VM). Os pacientes dentados internados na UTI adulta do hospital sem PAV e que necessitaram de ventilação mecânica por ≥ 48 horas durante um período de 4 meses em dois anos consecutivos (2015 - grupo Controle e 2016 - grupo Experimental) foram incluídos nesta investigação. O protocolo de higiene bucal foi implementado diariamente, uma vez ao dia, nas primeiras horas da manhã, utilizando-se escova descartável com cerdas de sucção e ultramacia e 3 g de gel de clorexidina a 0,12%. Dados de infecção respiratória relacionada ao hospital, incluindo diagnósticos de PAV e análises microbiológicas, foram coletados dos boletins mensais de notificação epidemiológica de saúde emitidos pelo hospital. Testes t foram aplicados para comparar as variáveis antes e após a implementação do protocolo de higiene bucal com um critério de significância de P <0,05. Observamos uma redução de 43,94% na taxa de PAV após a implementação do protocolo. A implementação do protocolo foi associada à uma redução significativa das infecções por Enterobacter spp e não foram identificados casos de PAV relacionados aos principais agentes etiológicos da doença (isto é, S. aureus e C. albicans). Pode-se concluir que u protocolo de higiene bucal realizado com escova de sucção e gel de clorexidina a 0,12% pode servir como uma profilaxia efetiva contra a PAV em pacientes sob ventilação mecânica.Palavras-chave: Unidade de Terapia Intensiva. Prevenção de Doenças. Higiene Bucal.

Ex Vivo Evaluation of Secretion-Clearing Device in Reducing Airway Resistance within Endotracheal Tubes

Background

Secretions accumulate in endotracheal tubes' (ETT) lumens upon their placement in patients. The secretions impact airway resistance and pressure. Secretions potentiate prolonged mechanical ventilation and ventilator-associated pneumonia. Our primary objective in this study was to evaluate an ETT-clearing device (ETT-CD) in its ability to remove secretions from ex vivo ETT lumens.

Methods

Forty ETTs, obtained from intensive care patients at extubation, were individually placed into a ventilator field performance testing simulator at 37°C. The pressure drop through the ETTs was measured at a flow rate of 60 L/min before and after cleaning with the ETT-CD and compared with unused, similarly sized controls tubes. The ETT-CD was inserted into an ETT until the tip reached Murphy's eye (hole in the side) of the ETT. The wiper, set back from the tip, was expanded by ETT-CD handle activation. As the ETT-CD was removed, the distal wiper extracted secretions from the ETT lumen.

Results

Forty ETTs were tested with nonparametric Wilcoxon signed-rank tests. Before being cleared with the ETT-CD, the median pressure drop in the extubated 7.5 mm ETTs was 17.8 cm H₂O; after ETT-CD use, it was 12.3. The cleared ETTs were significantly improved over the ETTs before being cleared (p < 0.001); however, there remained a significant difference between the cleared ETTs and the control tubes (p=0.005), indicating the clearing was not to the level of an unused ETT. Similar results were determined for the 8.0 mm ETTs.

Conclusions

For the 7.5 mm and the 8.0 mm EETs, the ETT-CD improved effective patency of the ETTs over the uncleared ETTs, independent of occlusion location, tube size, or length of tube. However, there remained a significant difference between the cleared tubes and controls.

Factors That Affect Oral Care Outcomes for Institutionalized Elderly

The aim of this study was to evaluate the effect of an oral care intervention program on the incidence of pneumonia and fever as a surrogate endpoint. In addition, we tried to determine the oral care risk factors for the incidence of fever. We provided an oral care program for the elderly at one private nursing home in July 2013. The maximum capacity of the nursing home was 60 residents. The body temperatures of all residents were measured twice a day and were summarized as the incidence of fever over a one-month period, which was used as the dependent variable. The residents' life conditions, number of teeth, and prescribed diet were used as independent variables. The factors that affected the incidence of fever were the number of remaining teeth, a prescribed diet of sliced food, the meal care level, and the oral Candida levels. These risk factors affected the incidence of fever independently or interactively with oral care. Some risk factors for the incidence of fever were enhanced by the oral care program. It is important to evaluate and control these factors before the implementation of an oral care program.

An assessment of endodontic treatment completion rate in a University-based student clinic and the factors associated with incomplete treatment

Incomplete endodontic treatment is potentially a public health issue. The aim of this retrospective study was to evaluate the endodontic treatment completion rate at a University student clinic and to identify the factors associated with completion rates. The records of all patients who commenced an endodontic treatment (code 415) from January 2015 to December 2015 were extracted. A total of 783 records were available for analysis of which 86% received complete endodontic treatment. Maxillary first molars were significantly associated with incomplete endodontic treatment (IET). Patients requiring an additional visit (code 455) were 1.5 times more likely to have an IET. The endodontic treatment completion rate at the School of Dentistry at the University of Queensland is higher than those reported in other international university-based student clinics. Focus group surveys of students and supervisors are required to identify the reasons for higher IET with maxillary first molars and code 455.

Perioperative intervention by oral medicine team in cardiovascular surgery patients

In brief, perioperative oral intervention consists of elimination of odontogenic foci and maintenance of oral hygiene in patients undergoing surgery. The importance of oral intervention before, during, and after medical treatments is well-known, especially in cancer patients, because odontogenic foci such as untreated deep dental caries or periodontitis can cause systemic infection in patients with myelosuppression resulting from chemotherapy. Although perioperative oral intervention is currently recommended for patients with cardiovascular disease, its efficacy in this population has not been established. This article consists of three sections: first, we review the current knowledge about the association between dental disease and cardiovascular disease to show the importance of oral hygiene maintenance and the risks of invasive dental procedures in patients with cardiovascular disease; second, we introduce pertinent, but limited evidence concerning the effect of oral care in preventing postoperative pneumonia; and finally, we present the optimal strategy for perioperative oral intervention in cardiovascular surgery patients.

Evaluation of Knowledge of the Oral Hygiene Protocol by the Nursing Team of the Intensive Care Unit of Two Hospitals In Londrina/PR

AbstractOral hygiene in the Intensive Care Unit - ICU is considered a basic and indispensable procedure whose goal is to maintain the patients’ healthy oral conditions, reducing complications and contributing to their recovery. The objective of this study was to evaluate the knowledge on  the oral hygiene protocol by the ICU nursing team of two hospitals in Londrina/PR. The sample of this study was composed by the nursing and nursing technicians team of the Intensive Care Unit of the Hospital A and Hospital B, regardless of gender or age, and considering who had worked at the ICU for at least three months. A self-administered, unidentified questionnaire was used to collect data. The analyzed variables were: profession, age, sex, working time and oral hygiene. More than 80% of the professionals were Nursing Technicians, with average age above 30, female and working in the ICU of the hospital for over 3.5 years. The results of this study demonstrate the lack of knowledge of the oral hygiene protocol by more than 30% of the Nursing staff in both hospitals. Based on the  methodology and the results analysis, it can be concluded that the oral hygiene protocol is unknown by more than a third of the ICU Nursing team of both  surveyed hospitals. Keywords: Intensive Care Units. Disease Prevention. Oral Hygiene.ResumoA higiene bucal em Unidade de Terapia Intensiva - UTI é considerada um procedimento básico e indispensável cujo objetivo é manter saudáveis as condições bucais dos pacientes, reduzindo agravos e contribuindo para sua recuperação. O objetivo deste estudo foi avaliar o conhecimento do protocolo de higiene bucal pela equipe de enfermagem da UTI de dois hospitais em Londrina/PR. A amostra deste estudo foi composta pela equipe de Enfermagem (Enfermeiros e Técnicos em Enfermagem) da Unidade de Terapia Intensiva do Hospital A e do Hospital B, independente do sexo e idade, e que trabalhavam na UTI, no mínimo, há três meses. Para a coleta de dados foi utilizado um questionário autoaplicável, não identificado. As variáveis analisadas foram: profissão, idade, sexo, tempo de trabalho e higiene bucal. Mais de 80% dos profissionais eram Técnicos em Enfermagem, com idade média acima dos 30 anos de idade, do sexo feminino e atuando na UTI do hospital, em média, acima de 3,5 anos. Os resultados deste estudo demonstram a falta de conhecimento do protocolo de higiene bucal, por mais de 30% da equipe de Enfermagem, em ambos os hospitais. Com base na metodologia e análise dos resultados, pode-se concluir que o protocolo de higiene bucal é desconhecido por mais de um terço da equipe de Enfermagem da UTI de ambos os hospitais pesquisados.Palavras-chave: Unidades de Terapia Intensiva. Prevenção de doenças. Higiene Bucal.

Effectiveness of Oral Rinsing Solutions on Mucus, Odor, and Plaque in the Hospitalized Elderly in Taiwan

This quasi-experimental and pretest-posttest study was conducted in Taiwan. The effectiveness of three types of oral rinsing solutions (normal saline, 0.2% chlorhexidine [CHX], and boiled water) was compared among 120 elderly patients (40 patients per group). Data on oral mucus, odor, and plaque were collected at admission on Day 1 (Time [T] 0), Day 4 (T1), Day 7 (T2), and Day 10 (T3). The results showed that the oral health condition in terms of mucus, plaque, and odor improved significantly over time. The effect for the oral condition did not differ significantly among the three groups, except for oral odor. At T2, the CHX group experienced higher oral odor than did the boiled water group (Solutions × Time interaction, F = 3.967, p = .002). Boiled water appears to be a safe and effective oral rinsing solution for hospitalized elderly patients.

Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate

BACKGROUND

Ventilator-associated pneumonia (VAP) in neonates can be reduced by implementing preventive care practices. Implementation of a group, or bundle, of evidence-based practices that improve processes of care has been shown to be cost-effective and to have better outcomes than implementation of individual single practices.

PURPOSE

The purpose of this article is to describe a safe, effective, and efficient neonatal VAP prevention protocol developed for caregivers in the neonatal intensive care unit (NICU). Improved understanding of VAP causes, effects of care practices, and rationale for interventions can help reduce VAP risk to neonatal patients.

METHOD

In order to improve care practices to affect VAP rates, initial and annual education occurred on improved protocol components after surveying staff practices and auditing documentation compliance.

FINDINGS/RESULTS

In 2009, a tertiary care level III NICU in the Midwestern United States had 14 VAP cases. Lacking evidence-based VAP prevention practices for neonates, effective adult strategies were modified to meet the complex needs of the ventilated neonate. A protocol was developed over time and resulted in an annual decrease in VAP until rates were zero for 20 consecutive months from October 2012 to May 2014.

IMPLICATIONS FOR PRACTICE

This article describes a VAP prevention protocol developed to address care practices surrounding hand hygiene, intubation, feeding, suctioning, positioning, oral care, and respiratory equipment in the NICU.

IMPLICATIONS FOR RESEARCH

Implementation of this VAP prevention protocol in other facilities with appropriate monitoring and tracking would provide broader support for standardization of care. Individual components of this VAP protocol could be studied to strengthen the inclusion of each; however, bundled interventions are often considered stronger when implemented as a whole.

The Prevalence of Oral Flora in the Biofilm Microbiota of the Endotracheal Tube

The endotracheal tube (ETT) is recognized as an independent factor for infection in intubated patients. The presence of biofilm contributes to the development of pneumonia. Standard culturing techniques are inadequate to detect many of the bacteria present in a biofilm. Delineation of the microbiota in the ETT is needed to further understand infections in ventilated patients. A prospective, observational study was performed at a university, Level I trauma center. Twenty ETT were collected at extubation. Bioluminal accretions were removed and quantified. DNA was extracted and 16S ribosomal RNA gene analysis performed using the Human Oral Microbe Identification Microarray. Twenty ETTwere evaluated. Mean age was 47.5 years (19–82). Five were smokers. Mean ventilator days was 3.6 ± 3.1. Mean intensive care unit days was 7.8 ± 6.3. In those ETT, 87 different bacterial species were identified. Mean number of bacterial species identified was 16 ± 9 (3–35). There was no relationship between duration of intubation and number of species ( P = 0.5). Nonsmokers had a greater variety of bacteria than smokers ( P = 0.03). Patients with pneumonia did not have a greater variety of bacteria ( P = 0.14). Parvimonas micra presence was associated with reintubation ( P = 0.01). The most common species in smokers were different from nonsmokers. There is a wide variety of bacteria present in an ETT, many of which cannot be cultured by standard means. Variation is not correlated to duration of intubation or accretion volume. Studies to evaluate these bacteria and their interaction with the biofilm may further delineate factors in development of infections.

Role of oral care to prevent VAP in mechanically ventilated Intensive Care Unit patients

Ventilator associated pneumonia (VAP) is the most common nosocomial infection in Intensive Care Unit. One major factor causing VAP is the aspiration of oral colonization because of poor oral care practices. We feel the role of simple measure like oral care is neglected, despite the ample evidence of it being instrumental in preventing VAP.

Randomized Controlled Trial and Meta-analysis of Oral Decontamination with 2% Chlorhexidine Solution for the Prevention of Ventilator-Associated Pneumonia

Objective.

To determine the effectiveness of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia (VAP).

Design.

Randomized controlled trial and meta-analysis.

Setting.

A tertiary care university hospital in Bangkok, Thailand.

Participants.

Adult patients who received mechanical ventilation and who were hospitalized in intensive care units and general medical wards.

Methods.

The patients were randomized to receive oral decontamination with 2% chlorhexidine solution or normal saline solution 4 times per day until their endotracheal tubes were removed. The outcome measures were the development of VAP and oropharyngeal colonization with gram-negative bacilli. Meta-analysis was performed by combining the results of the present study with those from another randomized controlled trial that also used a 2% chlorhexidine formulation for oral decontamination.

Results.

The characteristics of the patients in the chlorhexidine group (n= 102) and the normal saline group (n= 105) were not significantly different. The incidence of VAP in the chlorhexidine group was 4.9% (5 of 102), and the incidence in the normal saline group was 11.4% (12 of 105) (P= .08). The rate of VAP in the chlorhexidine group was 7 episodes per 1,000 ventilator-days, and the rate in the normal saline group was 21 episodes per 1,000 ventilator-days (P= .04). Irritation of the oral mucosa was observed in 10 (9.8%) of the patients in the chlorhexidine group and in 1 (0.9%) of the patients in the normal saline group (P= .001). Oropharyngeal colonization with gram-negative bacilli was either reduced or delayed in the chlorhexidine group. Overall mortality of the patients did not differ significantly between the groups. Meta-analysis of 2 randomized controlled trials revealed an overall relative risk of VAP for patients in the chlorhexidine group of 0.53 (95% confidence interval, 0.31-0.90;P= .02).

Conclusion.

Oral decontamination with 2% chlorhexidine solution is an effective and safe method for preventing VAP in patients who receive mechanical ventilation.

Influence of oral health condition on swallowing and oral intake level for patients affected by chronic stroke

BACKGROUND

According to the literature, the occurrence of dysphagia is high in cases of stroke, and its severity can be enhanced by loss of teeth and the use of poorly fitting prostheses.

OBJECTIVE

To verify that the status of oral health influences the level of oral intake and the degree of swallowing dysfunction in elderly patients with stroke in chronic phase.

METHODS

Thirty elderly individuals affected by stroke in chronic phase participated. All subjects underwent assessment of their oral condition, with classification from the Functional Oral Intake Scale (FOIS) and nasoendoscopic swallowing assessment to classify the degree of dysphagia. The statistical analysis examined a heterogeneous group (HG, n=30) and two groups designated by the affected body part, right (RHG, n=8) and left (LHG, n=11), excluding totally dentate or edentulous individuals without rehabilitation with more than one episode of stroke.

RESULTS

There was a negative correlation between the need for replacement prostheses and the FOIS scale for the HG (P=0.02) and RHG (P=0.01). Differences in FOIS between types of prostheses of the upper dental arch in the LHG (P=0.01) and lower dental arch in the RHG (P=0.04). A negative correlation was found between the number of teeth present and the degree of dysfunction in swallowing liquid in the LHG (P=0.05). There were differences in the performance in swallowing solids between individuals without prosthesis and those with partial prosthesis in the inferior dental arch (P=0.04) for the HG.

CONCLUSION

The need for replacement prostheses, type of prostheses, and the number of teeth of elderly patients poststroke in chronic phase showed an association with the level of oral intake and the degree of oropharyngeal dysphagia.

Healthcare-associated respiratory tract infection and colonization in an intensive care unit caused by Burkholderia cepacia isolated in mouthwash

OBJECTIVES

Burkholderia cepacia has been linked to healthcare-associated infections and colonization caused by contamination of alcohol-free mouthwash used in patients undergoing mechanical ventilation. The purpose of our study was to establish the source of a clustering of healthcare-associated B. cepacia isolates in patients on mechanical ventilation in the intensive care unit (ICU).

METHODS

During April 2012 the Infection Control Committee became concerned when B. cepacia was isolated from tracheal aspirate cultures of three ICU patients. The medical records for the years 2011 and 2012 were reviewed to identify further cases. Cultures of potential reservoirs were done. Isolates from patients and an alcohol-free mouthwash were submitted to multilocus sequence typing (MLST) analysis and antimicrobial resistance testing.

RESULTS

Four patients with positive cultures for B. cepacia were identified before the review of the medical records for the years 2011 and 2012. Nine further cases were identified in the review, defined as a patient with pneumonia who had a culture of respiratory secretions that was positive for B. cepacia. Three were cases of infection and 10 were colonizations. All of the isolates from patients (J, K, L, and M) and mouthwash samples (B19, B20, and B21) were genetically identical by MLST analysis.

CONCLUSIONS

Our findings strongly suggest that alcohol-free mouthwash solution intrinsically contaminated with B. cepacia was the source of these colonizations and infections involving adults in the ICU.

Endotracheal tube biofilm and ventilator-associated pneumonia with mechanical ventilation

OBJECTIVE

To analyze biofilm on internal and external surfaces of endotracheal tubes after their use in critical care patients, and to produce evidence of association between use of the tube, presence of biofilm, and the occurrence of pneumonia.

METHODS

This was a clinical study performed at the Intensive Care Unit of an emergency hospital in the interior of São Paulo state, Brazil. Data collection involved 30 endotracheal tubes used on adult patients for a period of ≥48 h of mechanical ventilation for scanning electron microscopy.

RESULTS

Analysis of the biofilm on the 30 tubes by scanning electron microscopy showed various abiotic and biotic structures, predominantly on the internal surface, such as: fibrin network, erythrocytes, leukocytes, cocci, bacilli, and molds, among others. The intubation period of the endotracheal tube for ≥8 days represented one of the risk factors for ventilator-associated pneumonia (RR 7.41, P < 0.001).

CONCLUSIONS

The presence of the endotracheal tube permits microbial colonization, overall contributing to the development of biofilm and the occurrence of pneumonia.

Respiratory medicine

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Upper respiratory infections are commonplace, especially in young people, and are often contagious

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Lower respiratory infections are often contagious and some are potentially fatal

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Asthma is common and may be life-threatening

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Chronic obstructive pulmonary disease is common and disabling

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Tuberculosis worldwide is an important infection, affecting people with HIV/AIDS or malnutrition particularly

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Lung cancer is common and usually has a poor prognosis

Aging effects on oropharyngeal swallow and the role of dental care in oropharyngeal dysphagia

Difficulty with oropharyngeal swallow requires careful diagnosis and treatment from a team of professionals including the patients' physicians and the speech-language pathologist specializing in dysphagia. The dentist can be a critical team member in prevention, early identification, and management of oropharyngeal dysphagia. This manuscript reviews the physiology of normal oropharyngeal swallow and the effects of normal aging on this physiology. Typical etiologies for oropharyngeal dysphagia are defined as is the most commonly used physiologic diagnostic procedure, the modified barium swallow (MBS). The critical role of the dentist in identifying risk of oropharyngeal dysphagia, making appropriate referrals, and improving oral hygiene to prevent aspiration pneumonia in the elderly is discussed.

One evidence based protocol doesn't fit all: brushing away ventilator associated pneumonia in trauma patients

OBJECTIVES

Evaluate change in ventilator associated pneumonia (VAP) and nurse's attitudes, beliefs post implementation of an evidence based practice (EBP) oral hygiene protocol. METHODOLOGY/DESIGN/SETTING: Descriptive pre and post test design in two critical care units in a Level One Trauma Community Hospital. Oral hygiene protocol data was reanalysed to examine effects in medical surgical and trauma subgroups.

OUTCOME MEASURES

Oral care practices, attitudes and beliefs among nurses, and VAP rates according to Centers for Disease Control and Prevention guidelines.

RESULTS

Trauma rates increased from 6.4% to 10.0% (p=0.346), and medical/surgical rates decreased from 3.3% to 1.0% (p=0.042). Results revealed changes in nurses' beliefs regarding pre-admission colonisation (p=0.027) and having adequate training. Nurses' perception of facility support improved, by having suitable equipment and readily available supplies. Foam swabs with moisture agents at 4hours or less was 88.6% and toothbrush use at 12hours or less was 71%, with significant changes in frequency of oral care post intervention.

CONCLUSIONS

Trauma patients present with unique characteristics which compromise oral care. Understanding risk and prognostic factors, mechanisms of transmission and systemic inflammatory response are important when implementing EBP protocols. Nurses' attitudes, beliefs are important, and staff adherence considered when initiating EBP changes.

Brushing teeth with purified water to reduce ventilator-associated pneumonia

BACKGROUND

Oral care may decrease the development of ventilator-associated pneumonia (VAP) and improve oral hygiene. However, little evidence is available to guide the development of oral care protocols. The practical effect of toothbrushing on VAP development and oral health and hygiene improvement is inconclusive.

PURPOSE

This study evaluated the effects in postneurosurgical, intensive care unit patients of brushing teeth twice daily with purified water on VAP rates and oral health or hygiene.

METHODS

This study conducted a randomized controlled pilot trial. Patients consecutively admitted to the surgical intensive care unit at a suburban hospital in 2007 were invited to participate if they met two inclusion criteria: (a) under ventilator support for at least 48 to 72 hours and (b) no current pneumonia. Upon obtaining informed consent, subjects were randomized into experimental and control groups. Both groups received usual hospital care, that is, daily oral care using cotton swabs. The experimental group additionally received a twice-daily oral care protocol of toothbrushing with purified water, elevating the head of the bed, and before-and-after hypopharyngeal suctioning. The control group also received twice-daily mock oral care (elevating the head of the bed, moisturizing the lips, and before-and-after hypopharyngeal suctioning). VAP was defined by a clinical pulmonary infection score of > 6. Oral hygiene and health was assessed after conclusion of the intervention.

RESULTS

Patients (N = 53) were predominantly male (64.2%), mean age was 60.6 years old, and most had received emergency surgery (75.5%). After 7 days of toothbrushing with purified water, cumulative VAP rates were significantly lower in the experimental (17%) than in the control (71%; p <.05) group. The experimental group also had significantly better scores for oral health (p <.05) and plaque index (p <.01). CONCLUSION/IMPLICATION FOR PRACTICE: Findings suggest that, as an inexpensive alternative to existing protocols, toothbrushing twice daily with purified water reduces VAP and improves oral health and hygiene.

Water, Water Everywhere, But Why? Argument Against Free Water Protocols

Free water protocols have become common in the management of patients with dysphagia. Their popularity has blossomed in the near-complete absence of any empirical data regarding their safety, efficacy and effectiveness. Proponents point to anecdotal reports and opinion pieces, while recent peer-reviewed investigation shows a mixed bag of safety and efficacy outcomes. This paper presents the argument against administration of “free water” without consideration of numerous factors besides the presence of dysphagia, and strongly urges the developers of the method to submit their data to peer review.

Critical care nurses' knowledge, attitudes and practices of oral care for patients with oral endotracheal intubation: a questionnaire survey

AIM

This study investigated intensive care unit nurses' knowledge, attitudes and practices of oral care for intubated patients together with the associated factors of the same.

BACKGROUND

Effective oral care improves patient comfort and prevents oral infection. Although oral care is a common requirement of nursing practice, providing intubated patients with oral care is a challenging task.

DESIGN

A descriptive, cross-sectional design.

METHODS

This study applied purposive sampling method at 12 adult intensive care units in one medical centre in northern Taiwan. Two hundred and five nurses were recruited. Data were collected by structured questionnaires which consisted of four sections: knowledge, attitudes and practices of oral care for intubated patients and demographic information for the nurses.

RESULTS

The average percentages indicating the intensive care unit nurses' oral care knowledge, attitudes and practices were 58·8, 79·4 and 49·8%, respectively. Higher scores on oral care knowledge were associated with nurses performing oral care more frequently. Nurses learning about oral care from reading related studies and materials of their own accord may increase the frequency with which they provide oral care to intubated patients. The nurses' age and the type of intensive care unit they work in were significant factors related to the frequency of performing practices related to oral care.

CONCLUSION

Findings show that nurses who have more resources for learning about oral care have greater knowledge about it and provide oral care to intubated patients more frequently.

RELEVANCE TO CLINICAL PRACTICE

Encouraging nurses to learn more about oral care using diverse educational resources will enhance their knowledge and improve their practice. Nursing administrators are encouraged to establish policies and procedures for oral care of intubated patients based on the type of patients cared for, in addition to holding in-service training, with a view to enhancing the quality of oral care for critically ill patients.

Preventing infections in patients using respiratory therapy equipment in the home

Although respiratory infections are not as common as other types of infections that may develop in home care and hospice patients, respiratory infections can result from the use of medical devices and respiratory supplies. These devices can contribute to the home care or hospice patient developing a respiratory infection by serving as a reservoir and supporting the growth of microorganisms and by directly infecting patients when this equipment becomes contaminated. This article presents evidenced-based guidelines and recommendations on the preferred methods for managing respiratory equipment and supplies commonly used by patients in the home setting and conducting surveillance activities to ultimately prevent respiratory infections.

Ventilator-associated pneumonia and oral care: a successful quality improvement project

BACKGROUND

Ventilator-associated pneumonia (VAP) is a nosocomial pneumonia that develops in patients on mechanical ventilation for >or=48 hours. VAP develops at an estimated rate of 1% to 3% per day of mechanical ventilation.

METHODS

Quality improvement project. Mechanically ventilated patients received the following oral care every 4 hours: the teeth were brushed with cetylpyridinium chloride (changed to 0.12% chlorhexidine gluconate in 2007) using a suction toothbrush, the oral cavity was cleansed with suction swabs treated with hydrogen peroxide, a mouth moisturizer was applied, deep oropharyngeal suctioning was performed, and suction catheters were used to control secretions. The primary efficacy variable was a diagnosis of VAP in patients mechanically ventilated for >or=48 hours.

RESULTS

The historical average rate of VAP in 2004 was 12.6 cases/1000 ventilator-days. After the inception of the quality improvement project, VAP rates decreased to 4.12 (VAP cases/days of ventilation x 1000) for May to December 2005, to 3.57 for 2006, and to 1.3 for 2007.

CONCLUSION

The use of an oral care protocol intervention and ventilator bundle led to an 89.7% reduction in the VAP rate in mechanically ventilated patients from 2004 to 2007.

The relationship of periodontal disease to diseases and disorders at distant sites: communication to health care professionals and patients

BACKGROUND

The body of research defining relationships among periodontal disease and certain systemic diseases and disorders has been expanding, and questions have been raised regarding what information should be conveyed to health care professionals and patients.

METHODS

Representatives from dentistry, medicine, the academic community and the insurance industry convened a two-day workshop July 23 and 24, 2007.

RESULTS

The workshop participants achieved general consensus on a number of issues, including the need for greater cooperation between the health care professions. This cooperation should translate into improved clinical care as physicians refer patients for dental care, and dentists are proactive in regard to the general health of their patients.

CONCLUSION

Communication to health care professionals requires a multifaceted approach that includes publication of research findings in medical and dental journals, cooperation among professional organizations and initiatives at the local level such as presentations at medical grand rounds. Dental schools should play a role in their health science centers. Communication with patients may improve through the use of targeted informational brochures in the offices of medical specialists, appropriate media campaigns and efforts led by local dental organizations.

PRACTICE IMPLICATIONS

It is too early to provide specific recommendations regarding the treatment of periodontal disease to improve specific health outcomes, but dentists can become advocates for a general health promotion and disease prevention message. The lifestyles approach includes an improved diet, smoking cessation, appropriate hygiene practices and stress reduction. These strategies can improve oral and general health outcomes.

Higiene bucal com clorexidina na prevenção de pneumonia associada à ventilação mecânica

A pneumonia associada à ventilação mecânica (PAVM) é uma infecção freqüente nas unidades de terapia intensiva (UTI), e anti-sépticos bucais são utilizados preventivamente. Revisamos metanálises e ensaios clínicos randomizados indexados no Medical Literature Analysis and Retrieval System e Cumulative Index to Nursing and Allied Health Literature sobre o uso tópico da clorexidina na prevenção da PAVM. Oito publicações foram avaliadas. Em sete (87,5%), a clorexidina diminuiu a colonização da orofaringe, e em quatro (50%) houve redução de PAVM. A clorexidina parece diminuir a colonização, podendo reduzir a incidência da PAVM.

Role of the lysozyme inhibitor Ivy in growth or survival of Escherichia coli and Pseudomonas aeruginosa bacteria in hen egg white and in human saliva and breast milk

Ivy is a lysozyme inhibitor that protects Escherichia coli against lysozyme-mediated cell wall hydrolysis when the outer membrane is permeabilized by mutation or by chemical or physical stress. In the current work, we have investigated whether Ivy is necessary for the survival or growth of E. coli MG1655 and Pseudomonas aeruginosa PAO1 in hen egg white and in human saliva and breast milk, which are naturally rich in lysozyme and in membrane-permeabilizing components. Wild-type E. coli was able to grow in saliva and breast milk but showed partial inactivation in egg white. The knockout of Ivy did not affect growth in breast milk but slightly increased sensitivity to egg white and caused hypersensitivity to saliva, resulting in the complete inactivation of 10(4) CFU ml(-1) of bacteria within less than 5 hours. The depletion of lysozyme from saliva completely restored the ability of the ivy mutant to grow like the parental strain. P. aeruginosa, in contrast, showed growth in all three substrates, which was not affected by the knockout of Ivy production. These results indicate that lysozyme inhibitors like Ivy promote bacterial survival or growth in particular lysozyme-rich secretions and suggest that they may promote the bacterial colonization of specific niches in the animal host.

Removal of oral secretion prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: a clinical controlled trial study

AIM

The purpose of this study was to explore the effect of oral secretion on aspiration and reducing ventilator-associated pneumonia.

BACKGROUND

Ventilator-associated pneumonia is a serious hospital-acquired infection with reported incidence rate of 12.2% and mortality rate of 29.3%. Oral secretion is purported as a media which brings the oropharyngeal pathogens down to the respiratory track.

METHODS

Two-group comparison study design was adopted. Subjects were recruited from an adult general intensive care unit of a medical centre in Taipei city. Patients in the study group received suction of oral secretion before each positional care, in contrast with patients in the control group who received routine care.

RESULTS

Ventilator-associated pneumonia was found in 24 of 159 (15.1%) patients in the control group and in five of 102 (4.9%) patients in the study group with a reduction of risk ratio of 0.32 (95% CI 0.11-0.92). Eight of the 24 ventilator-associated pneumonia patients died in the control group; however, none of those ventilator-associated pneumonia patients died in the study group. The increased chance of survival was 1.50 (95% CI 1.13-1.99). The length of stay in ICU and duration of mechanical ventilation were reduced in the study group. In consideration of cost, the cost of tubes used to remove oral secretion is much less than the one used to do continuous subglottal suction.

CONCLUSION

Removal of oral secretion is effective in reducing the incidence of ventilator-associated pneumonia with minimum cost intervention.

RELEVANCE TO CLINICAL PRACTICE

This study provides evidence that removal of oral secretion prior to position change is cost effective to reduce the incidence of ventilator-associated pneumonia. As such intervention is an easy task, routine removal of oral secretion is recommended as the standard of daily nursing care of patients on ventilator.

Interventional patient hygiene model: Infection control and nursing share responsibility for patient safety

Interventional patient hygiene (IPH) has been defined as a comprehensive evidence-based intervention and measurement model for reducing the bioburden of both the patient and health care worker. The components of IPH are hand hygiene, oral care, skin care/antisepsis, and catheter site care. This practice form will provide evidence-based information for each of the components of IPH model and provide a strategy for the development, implementation, and monitoring of IPH protocols.

Oral biofilms, periodontitis, and pulmonary infections

Bacteria from the oral biofilms may be aspirated into the respiratory tract to influence the initiation and progression of systemic infectious conditions such as pneumonia. Oral bacteria, poor oral hygiene, and periodontitis seem to influence the incidence of pulmonary infections, especially nosocomial pneumonia episodes in high-risk subjects. Improved oral hygiene has been shown to reduce the occurrence of nosocomial pneumonia, both in mechanically-ventilated hospital patients and non-ventilated nursing home residents. It appears that oral colonization by potential respiratory pathogens, possibly fostered by periodontitis, and possibly by bacteria specific to the oral cavity or to periodontal diseases contribute to pulmonary infections. Thus, oral hygiene will assume an even more important role in the care of high-risk subjects--patients in the hospital intensive care and the elderly. The present paper critically reviews the recent literature on the effect of oral biofilms and periodontitis on pneumonia.

Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation

Background Oropharyngeal colonization with pathogenic organisms contributes to the development of ventilator-associated pneumonia in intensive care units. Although considered basic and potentially nonessential nursing care, oral hygiene has been proposed as a key intervention for reducing ventilator-associated pneumonia. Nevertheless, evidence from randomized controlled trials that could inform best practice is limited.

Objective To appraise the peer-reviewed literature to determine the best available evidence for providing oral care to intensive care patients receiving mechanical ventilation and to document a research agenda for this important activity in optimizing patients’ outcomes.

Methods Articles published from 1985 to 2006 in English and indexed in the CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, EMBASE, and DARE databases were searched by using the key terms oral hygiene, oral hygiene practices, oral care, mouth care, mouth hygiene, intubated, mechanically ventilated, intensive care, and critical care. Reference lists of retrieved journal articles were searched for publications missed during the primary search. Finally, the Google search engine was used to do a comprehensive search of the World Wide Web to ensure completeness of the search. The search strategy was verified by a health librarian.

Results The search yielded 55 articles: 11 prospective controlled trials, 20 observational studies, and 24 descriptive reports. Methodological issues and the heterogeneity of samples precluded meta-analysis.

Conclusions Despite the importance of providing oral hygiene to intensive care patients receiving mechanical ventilation, high-level evidence from rigorous randomized controlled trials or high-quality systematic reviews that could inform clinical practice is scarce.

Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement in the ICU

The health care culture must change. Florence Nightingale wrote [8] "deep-rooted and universal is the conviction that to give a medicine is to be doing something, or rather everything and to give air, warmth, cleanliness etc. is to do nothing." Hygiene care practices and mobility activities are fundamental and independent care components in the nursing profession. When implemented using available evidence, they can significantly improve patient outcomes. It is time to claim and demonstrate the importance of consistent delivery of the fundamentals of basic nursing care. Interventional patient hygiene is an effective framework to ensure the the basics of nursing care are consistently applied to improve patient outcomes.

Topical chlorhexidine for prevention of ventilator-associated pneumonia: A meta-analysis*

OBJECTIVE

To assess the efficacy of topical chlorhexidine for prevention of ventilator-associated pneumonia (VAP) in a meta-analysis.

DATA SOURCE

Computerized PubMed and MEDLINE search supplemented by manual searches for relevant articles.

STUDY SELECTION

Randomized controlled trials evaluating efficacy of topical chlorhexidine applied to the oropharynx vs. placebo or standard care for prevention of VAP.

DATA EXTRACTION

Data were extracted on patient population, inclusion and exclusion criteria, diagnostic criteria for VAP, form and concentration of topical chlorhexidine used, incidence of VAP, and overall mortality.

DATA SYNTHESIS

Data on incidence of VAP and mortality were abstracted as dichotomous variables. Pooled estimates of the relative risk and 95% confidence intervals were obtained using the DerSimonian and Laird random effects model and the Mantel-Haenszel fixed effects model. Heterogeneity was assessed using the Cochran Q statistic and I. Subgroup analyses were used to explore heterogeneity.

RESULTS

Seven randomized controlled trials met the inclusion criteria. Topical chlorhexidine resulted in a reduced incidence of VAP (relative risk, 0.74; 95% confidence interval, 0.56-0.96; p=.02) using a fixed effects model. Using the more conservative random effects model, the point estimate was similar (relative risk, 0.70; 95% confidence interval, 0.47-1.04; p=.07), but the results failed to achieve statistical significance. The I test showed moderate heterogeneity. Subgroup analysis showed that the benefit of chlorhexidine was most marked in cardiac surgery patients (relative risk, 0.41; 95% confidence interval, 0.17-0.98; p=.04). There was no mortality benefit with chlorhexidine although the sample size was small.

CONCLUSIONS

Our analysis showed that topical chlorhexidine is beneficial in preventing VAP; the benefit is most marked in cardiac surgery patients. A large randomized trial is needed to determine the impact of topical chlorhexidine on mortality.