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He Q, Peng Z, He C, Zhang C, Hu R. Effect of different mouthwashes on ventilator-related outcomes and mortality in intensive care unit patients: A network meta-analysis. Aust Crit Care 2024:S1036-7314(24)00205-4. [PMID: 39179488 DOI: 10.1016/j.aucc.2024.06.014] [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: 01/09/2024] [Revised: 06/04/2024] [Accepted: 06/23/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Ventilator-associated pneumonia is a common and life-threatening complication in intensive care unit (ICU) patients. Maintaining oral hygiene is crucial for reducing ventilator-associated pneumonia incidence. Various mouthwash solutions are used for oral care in ICU settings, but their comparative effectiveness remains unclear. This study aims to systematically evaluate and compare the efficacy and safety of commonly used mouthwashes for oral care in mechanically ventilated ICU patients. METHODS We searched PubMed, Web of Science, Embase, and Cochrane Library for randomised controlled trials (RCTs) comparing saline, chlorhexidine, sodium bicarbonate, oxidising agents, herbal extracts, and povidone-iodine for oral care in ventilated ICU patients. Outcomes included ventilator-associated pneumonia incidence, ICU mortality, duration of ventilation, and Escherichia coli fixed value. A network meta-analysis (NMA) was conducted to synthesise direct and indirect evidence. This study is registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols, 2023120028. RESULTS FourteenRCTs with 1644 participants were included. Oxidising agents showed a trend towards reducing the incidence of VAP compared to the control group (risk ratio: 0.24, 95% confidence interval: 0.05-1.10). Administration of saline was associated with a notable reduction in ICU mortality (risk ratio: 0.18, 95% confidence interval: 0.04-0.88) versus no mouthwash. No significant differences were observed in the duration of mechanical ventilation between chlorhexidine, povidone-iodine, and the control group. CONCLUSIONS Antimicrobial mouthwashes, especially chlorhexidine, pose potential risks in ICU patients; oxidising solutions demonstrate relative safety. Saline solution emerges as a promising alternative, associated with a significant reduction in mortality rates. However, the need for large, high-quality RCTs remains paramount to substantiate these findings and establish evidence-based oral-care protocols in ICU settings. REGISTRATION This study is registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols, 2023120028.
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Affiliation(s)
- Qianqian He
- Medical College, Hunan Normal University, No. 371 Tongzipo Road, Yuelu District, Changsha, Hunan, China.
| | - Zengjin Peng
- Medical College, Hunan Normal University, No. 371 Tongzipo Road, Yuelu District, Changsha, Hunan, China; Department of Internal Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, No. 139 Middle Renmin Road, Furong District, Changsha, Hunan, China.
| | - Caiyun He
- Medical College, Hunan Normal University, No. 371 Tongzipo Road, Yuelu District, Changsha, Hunan, China.
| | - Chao Zhang
- Nursing Department, School of Nursing, Shandong University of Traditional Chinese Medicine, 16369 Jingshi Road, Lixia District, Jinan, Shandong 250014, China.
| | - Rong Hu
- Medical College, Hunan Normal University, No. 371 Tongzipo Road, Yuelu District, Changsha, Hunan, China.
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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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Kelly N, Blackwood B, Credland N, Stayt L, Causey C, Winning L, McAuley DF, Lundy FT, El Karim I. Oral health care in adult intensive care units: A national point prevalence study. Nurs Crit Care 2023; 28:773-780. [PMID: 37125669 DOI: 10.1111/nicc.12919] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 03/30/2023] [Accepted: 04/06/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND The importance of good oral hygiene for patients in Intensive Care Units (ICUs) is well recognized, however, the most effective way to achieve good oral care in the ICU is unclear. AIM This study aimed to provide a national picture of oral care practices in adult ICUs in the United Kingdom (UK) to identify areas for improvement. STUDY DESIGN A national one-day point prevalence study was undertaken in adult ICUs in the UK in the period from 30th September to 14th October 2021. Data were collected on all patients in the ICU on the date of data collection. Using a validated electronic data collection form, anonymised data were collected on methods and frequency of oral care provided, and the use of oral care protocols within the ICU. Data were analysed using descriptive analysis. RESULTS Data from 195 patients in 15 ICUs in England, Wales and Northern Ireland were collected. Written oral care protocols were available for use in the care of 65% (n = 127) of patients. 73% (n = 142) of patients received oral care within the 24-h period. Oral care methods included toothbrushing 41% (n = 79), foam sticks 3% (n = 5), moisturizing the oral cavity 10% (n = 19) and mouth rinse with chlorhexidine 3% (n = 5) and other oral care methods not specified 12% (n = 23). 44% (n = 85) of patients had an oral assessment within the 24-h period and variable assessment methods were used. CONCLUSION There is large variability in oral care provision and methods for intubated ICU patients and a lack of consensus was revealed in the study. Oral assessment is conducted less frequently using multiple tools. Optimal oral care standards and further research into oral care provision is pivotal to address this important patient-relevant practice. RELEVANCE TO CLINICAL PRACTICE Oral care is a fundamental part of care for ICU patients, however, there is a large degree of variability, and oral care is often not based upon oral assessment. The use of an oral care protocol and oral assessments would help to improve patient care, ease of use for staff and provide a tailored oral care plan for patients, improving efficiency and preventing wasted resources.
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Affiliation(s)
- Niamh Kelly
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Nicki Credland
- Faculty of Health Sciences, University of Hull, Hull, UK
| | - Louise Stayt
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Christine Causey
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Lewis Winning
- Division of Restorative Dentistry & Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Fionnuala T Lundy
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Ikhlas El Karim
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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Cruz JC, Martins CK, Piassi JEV, Garcia Júnior IR, Santiago Junior JF, Faverani LP. Does chlorhexidine reduce the incidence of ventilator-associated pneumonia in ICU patients? A systematic review and meta-analysis. Med Intensiva 2023; 47:437-444. [PMID: 36464582 DOI: 10.1016/j.medine.2022.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE This study aimed to investigate chlorhexidine's efficacy in preventing ventilator-associated pneumonia (VAP). DESIGN A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. SETTINGS The data were obtained from Pubmed, Cochrane Library, and EMBASE. PATIENTS OR PARTICIPANTS Only mechanically ventilated patients for at least 48h were included. INTERVENTIONS Randomized clinical trials applying any dosage form of chlorhexidine were eligible. MAIN VARIABLES OF INTEREST The relative risk (RR) of the VAP incidence and all-cause mortality was assessed using the random-effects model. The mean difference in days of mechanical ventilation duration and intensive care unit (ICU) length of stay were also appraised. RESULTS Ten studies involving 1233 patients were included in the meta-analysis. The oral application of CHX reduced the incidence of VAP (RR, 0.73 [95% CI, 0.55, 0.97]) and did not show an increase in all-cause mortality (RR, 1.13 [95% CI, 0.96, 1.32]). CONCLUSIONS CHX proved effective to prevent VAP. However, a conclusion on mortality rates could not be drawn because the quality of the evidence was very low for this outcome.
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Affiliation(s)
- J C Cruz
- University of São Paulo (USP), Ribeirão Preto, Brazil.
| | - C K Martins
- Department of Medicine, University of Ribeirão Preto (UNAERP), Ribeirão Preto, Brazil
| | - J E V Piassi
- Division of Oral and Maxillofacial Surgery, Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil
| | - I R Garcia Júnior
- Division of Oral and Maxillofacial Surgery, Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil
| | - J F Santiago Junior
- Department of Health Sciences. Dentistry Course, Unisagrado: Centro Universitário Sagrado Coração, Bauru, SP, Brazil
| | - L P Faverani
- Division of Oral and Maxillofacial Surgery, Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil
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Fu LS, Zhu LM, Yang YP, Lin L, Yao LQ. Impact of oral care modalities on the incidence of ventilator-associated pneumonia in the intensive care unit: A meta-analysis. Medicine (Baltimore) 2023; 102:e33418. [PMID: 37000078 PMCID: PMC10063266 DOI: 10.1097/md.0000000000033418] [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: 01/08/2023] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND At present, evidence of the role of oral hygiene in ICU-related pneumonia is rare. The study aimed to evaluate the effectiveness of toothbrush-based oral care in preventing ventilator-associated pneumonia (VAP) in patients with mechanical ventilation in the ICU. METHODS Ten databases were searched for randomized controlled trials (RCTs) evaluating toothbrush-based oral care for preventing VAP in patients with mechanical ventilation in ICU. Quality assessment and data extraction were independently performed by 2 researchers. The meta-analysis was performed using RevMan 5.3 software. RESULTS Thirteen RCTs with 657 patients were included. Tooth brushing + 0.2%/0.12% chlorhexidine was associated with reduced incidence of VAP compared to chlorhexidine (OR = 0.63, 95% confidence interval [CI]: 0.43-0.91, P = .01) or tooth brushing + placebo (OR = 0.47, 95% CI: 0.25-0.86, P = .02) in patients with mechanical ventilation in ICU, but was similar to cotton wipe with 0.2% or 0.12% chlorhexidine (OR = 1.33, 95% CI: 0.77-2.29, P = .31). CONCLUSIONS Tooth brushing combined with chlorhexidine mouthwash can prevent VAP in patients with mechanical ventilation in ICU. There is no advantage of tooth brushing combined with chlorhexidine mouthwash over cotton wipe with chlorhexidine mouthwash for preventing VAP in these patients.
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Affiliation(s)
- Li-Sang Fu
- The Affiliated Hospital of Putian University, Putian, Fujian Province, China
| | - Li-Mei Zhu
- The Affiliated Hospital of Putian University, Putian, Fujian Province, China
| | - Yuan-Ping Yang
- The Affiliated Hospital of Putian University, Putian, Fujian Province, China
| | - Ling Lin
- The Affiliated Hospital of Putian University, Putian, Fujian Province, China
| | - Li-Qun Yao
- Charles Darwin University, Faculty of Health, Brisbane Centre, Australia
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6
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Oral care to reduce costs and increase clinical effectiveness in preventing nosocomial pneumonia: a systematic review. J Evid Based Dent Pract 2023; 23:101834. [DOI: 10.1016/j.jebdp.2023.101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 12/27/2022] [Accepted: 01/19/2023] [Indexed: 01/30/2023]
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7
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Xiang Y, Ren X, Xu Y, Cheng L, Cai H, Hu T. Anti-Inflammatory and Anti-Bacterial Effects of Mouthwashes in Intensive Care Units: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:733. [PMID: 36613055 PMCID: PMC9819176 DOI: 10.3390/ijerph20010733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/25/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
Mouthwashes are used as oral care for critical care patients to prevent infections. However, there are conflicting data concerning whether mouthwashes are needed as a part of daily oral care for critical care patients. This study aimed to evaluate the anti-inflammatory and anti-bacterial effects of mouthwashes for critical care patients. The PubMed, EMBASE, CENTRAL, and grey literature databases were searched by descriptors combining population (intensive care unit patients) and intervention (mouthwashes). After the screening, only randomized controlled trials (RCTs) evaluating the anti-inflammatory and anti-bacterial effects of mouthwashes in patient critical care were included. From the 1531 articles, 16 RCTs satisfied the eligibility criteria for systematic review and 10 were included in the meta-analyses. A significant difference was found in the incidence of ventilator associated pneumonia (VAP) (odds ratio [OR] 0.53, 95% confidential interval [95% CI] 0.33 to 0.86) between the mouthwash and placebo groups, while no significant difference was found in the mortality (OR 1.49, 95%CI 0.92 to 2.40); the duration of mechanical ventilation (weighted mean difference [WMD] -0.10, 95%CI -2.01 to 1.81); and the colonization of Staphylococcus aureus (OR 0.88, 95%CI 0.34 to 2.30), Escherichia coli (OR 1.19, 95%CI 0.50 to 2.82), and Pseudomonas aeruginosa (OR 1.16, 95%CI 0.27 to 4.91) between the two groups. In conclusion, mouthwashes were effective in decreasing the incidence of VAP. Thus, mouthwashes can be used as part of daily oral care for critical care patients.
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Affiliation(s)
| | | | | | | | - He Cai
- Correspondence: (H.C.); (T.H.); Tel.: +86-028-8550-3486 (H.C.); +86-028-8550-3486 (T.H.)
| | - Tao Hu
- Correspondence: (H.C.); (T.H.); Tel.: +86-028-8550-3486 (H.C.); +86-028-8550-3486 (T.H.)
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8
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Yang L, Zhang Q, Zhai H. Comparative efficacy of different concentrations of chlorhexidine for prevention of
ventilator‐associated
pneumonia in intensive care units: A systematic review and network
meta‐analysis. Nurs Crit Care 2022. [DOI: 10.1111/nicc.12849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Li Yang
- The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University Lianyungang China
| | - Qin Zhang
- The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University Lianyungang China
| | - Huaixiang Zhai
- The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University Lianyungang China
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9
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Dai W, Lin Y, Yang X, Huang P, Xia L, Ma J. Meta-Analysis of the Efficacy and Safety of Chlorhexidine for Ventilator-Associated Pneumonia Prevention in Mechanically Ventilated Patients. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:5311034. [PMID: 35942379 PMCID: PMC9356777 DOI: 10.1155/2022/5311034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/17/2022]
Abstract
Objective To explore the efficacy and safety of chlorhexidine oral care in the prevention of ventilator-associated pneumonia (VAP) by means of meta-analysis. Methods Randomized controlled trials on the effect of chlorhexidine oral care on the incidence of VAP in patients on mechanical ventilation were searched in PubMed, Scopus, Cochrane Library, and Embase from May 1, 2022. Two researchers independently screened and included the study, extracted the data, and evaluated the literature quality. RevMan5.3 software was used for meta-analysis. Results Meta-analysis of 13 included literature studies involving 1533 patients showed that oral care with chlorhexidine solution could reduce the incidence of VAP in patients with mechanical ventilation and the difference was statistically significant (RR = 0.61, 95% CI (0.46, 0.82), P=0.04). However, the results showed that the incidence of VAP of low concentration (0.02%, 0.12%, and 0.2%) and high concentration (2%) of chlorhexidine in the intervention group was lower than that in the control group and the difference was statistically significant (RR = 0.70, 95% CI (0.51, 0.96), P=0.03; RR = 0.41, 95% CI (0.27, 0.62)). There was no significant difference in mortality between the two groups (RR = 1.01, 95% CI (0.85, 1.21), P=0.87). There was no statistical significance in days ventilated or days in ICU between the two groups (RR = -0.02, 95% CI (-0.19, 0.16), P=0.84; RR = 0.01, 95% CI (-0.11, 0.14), P=0.85). Conclusion Existing evidence shows that chlorhexidine used for oral care of patients with mechanical ventilation can reduce the incidence of VAP, and high concentration of chlorhexidine (2%) or low concentration of chlorhexidine (0.02%, 0.12%, 0.2%) has a significant effect on the prevention of VAP. Considering the safety of clinical application, it is recommended to use 0.02%, 0.12%, and 0.2% chlorhexidine solution for oral care.
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Affiliation(s)
- Weiying Dai
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yao Lin
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiangying Yang
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Pei Huang
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Liuqin Xia
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jianping Ma
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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10
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Sozkes S, Sozkes S. Use of toothbrushing in conjunction with chlorhexidine for preventing ventilator-associated pneumonia: A random-effect meta-analysis of randomized controlled trials. Int J Dent Hyg 2021; 21:389-397. [PMID: 34687588 DOI: 10.1111/idh.12560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 09/19/2021] [Accepted: 10/20/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The oral cavity with poor hygiene is a reservoir of a complex community of commensal and pathogenic bacteria. Improved oral hygiene (OH) may reduce the incidence of ventilator-associated pneumonia (VAP); however, research on the efficacy of different OH treatments and their potential synergistic effects has remained inconclusive. The objective of this study was to examine whether in patients on mechanical ventilation, using a toothbrushing (T) in conjunction with chlorhexidine (CHX), as opposed to only CHX, reduced the incidence of VAP. METHOD A random-effect meta-analysis of randomized clinical trials, which compare the effect of CHX+T (intervention) with CHX (control) on the risk of VAP, was conducted. The Mantel-Haenszel model was used to determine the mean differences (MD), relative risks (RR) and 95% confidence intervals (CI). RESULTS Seven studies with 1424 patients were included. Oral care with CHX+T reduced the incidences of VAP (RR = 0.67; CI = [0.50, 0.88], p = 0.005) compared with that with CHX alone. The former also reduced the duration of mechanical ventilation (MD = -1.38; CI = [-2.43, -0.33], p = 0.01) and length of stay in the ICU (MD = -1.47; CI = [-2.74, -0.20], p = 0.02), although the risk of ICU mortality did not reduce (RR = 0.87, 95% CI = [0.72, 1.04], p = 0.17). CONCLUSIONS Toothbrushing along with CHX significantly reduced the risk of VAP. Further well-designed randomized controlled trials with a careful focus on the OH are needed to fully establish the advantage of toothbrushing along with CHX for reducing the risk of VAP.
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Affiliation(s)
- Serda Sozkes
- Intensive Care Unit and Reanimation Department, Saglik Bakanligi Istanbul Catalca Ilyas Cokay Public Hospital, Istanbul, Turkey
| | - Sarkis Sozkes
- CMF Biomedical Engineering Biomaterials Department, Tekirdag Namik Kemal University, Tekirdag, Turkey
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11
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Silva PUJ, Paranhos LR, Meneses-Santos D, Blumenberg C, Macedo DR, Cardoso SV. Combination of toothbrushing and chlorhexidine compared with exclusive use of chlorhexidine to reduce the risk of ventilator-associated pneumonia: A systematic review with meta-analysis. Clinics (Sao Paulo) 2021; 76:e2659. [PMID: 34133659 PMCID: PMC8158674 DOI: 10.6061/clinics/2021/e2659] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/15/2021] [Indexed: 01/08/2023] Open
Abstract
This study aimed to compare the effectiveness of 0.12% chlorhexidine alone and 0.12% chlorhexidine in combination with toothbrushing to prevent ventilator-associated pneumonia (VAP) in mechanically ventilated patients. The Embase, Latin American and Caribbean Health Science Literature, PubMed, Scientific Electronic Library Online, Scopus, LIVIVO, Web of Science, Cochrane Library, OpenThesis, and Open Access Thesis and Dissertations databases were used. Only randomized controlled trials without restrictions on the year or language of publication were included. Two reviewers assessed the risk of bias using the Joanna Briggs Institute Critical Appraisal Tool. A meta-analysis using a random-effects model estimated the combined relative risk (RR). The Grading of Recommendations, Assessment, Development and Evaluations approach was used to assess the certainty of the evidence. Initially, 2,337 studies were identified, of which 4 were considered in the systematic review and 3 in the meta-analysis (total sample: 796 patients). The studies were published between 2009 and 2017. All eligible studies had a low risk of bias. The meta-analysis revealed that the risk of VAP was 24% lower in patients receiving chlorhexidine combined with toothbrushing than in those receiving chlorhexidine alone (RR: 0.76; 95% confidence interval: 0.55-1.06), with moderate certainty of evidence and without statistical significance. In conclusion, considering the limitations of this study, a standard protocol for the prevention of VAP is not yet recommended. More studies with larger sample sizes are needed to draw strong conclusions. However, considering that toothbrushing is a simple intervention, it should be a common practice in mechanically ventilated patients, especially among patients with coronavirus disease.
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Affiliation(s)
- Pedro Urquiza Jayme Silva
- Programa de Pos-Graduacao em Odontologia, Faculdade de Odontologia, Universidade Federal de Uberlandia, Uberlandia, MG, BR
| | - Luiz Renato Paranhos
- Area de Odontologia Preventiva e Social, Faculdade de Odontologia, Universidade Federal de Uberlandia, Uberlandia, MG, BR
- Corresponding author. E-mail:
| | - Daniela Meneses-Santos
- Programa de Residencia em Cirurgia e Traumatologia Buco-Maxilo-Facial, Faculdade de Medicina, Universidade Federal de Uberlandia, Uberlandia, MG, BR
| | - Cauane Blumenberg
- Programa de Pos-Graduacao em Epidemiologia, Faculdade de Medicina, Universidade Federal de Pelotas, Pelotas, RS, BR
| | | | - Sérgio Vitorino Cardoso
- Area de Patologia, Faculdade de Odontologia, Universidade Federal de Uberlandia, Uberlandia, MG, BR
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Zhao T, Wu X, Zhang Q, Li C, Worthington HV, Hua F. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev 2020; 12:CD008367. [PMID: 33368159 PMCID: PMC8111488 DOI: 10.1002/14651858.cd008367.pub4] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in people who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, swab, toothbrush, or combination, together with suction of secretions, may reduce the risk of VAP in these patients. OBJECTIVES To assess the effects of oral hygiene care (OHC) on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs). SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 25 February 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 1), MEDLINE Ovid (1946 to 25 February 2020), Embase Ovid (1980 to 25 February 2020), LILACS BIREME Virtual Health Library (1982 to 25 February 2020) and CINAHL EBSCO (1937 to 25 February 2020). We also searched the VIP Database (January 2012 to 8 March 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, gel, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data and assessed risk of bias in included studies. We contacted study authors for additional information. We reported risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, using the random-effects model of meta-analysis when data from four or more trials were combined. MAIN RESULTS We included 40 RCTs (5675 participants), which were conducted in various countries including China, USA, Brazil and Iran. We categorised these RCTs into five main comparisons: chlorhexidine (CHX) mouthrinse or gel versus placebo/usual care; CHX mouthrinse versus other oral care agents; toothbrushing (± antiseptics) versus no toothbrushing (± antiseptics); powered versus manual toothbrushing; and comparisons of other oral care agents used in OHC (other oral care agents versus placebo/usual care, or head-to-head comparisons between other oral care agents). We assessed the overall risk of bias as high in 31 trials and low in two, with the rest being unclear. Moderate-certainty evidence from 13 RCTs (1206 participants, 92% adults) shows that CHX mouthrinse or gel, as part of OHC, probably reduces the incidence of VAP compared to placebo or usual care from 26% to about 18% (RR 0.67, 95% confidence intervals (CI) 0.47 to 0.97; P = 0.03; I2 = 66%). This is equivalent to a number needed to treat for an additional beneficial outcome (NNTB) of 12 (95% CI 7 to 128), i.e. providing OHC including CHX for 12 ventilated patients in intensive care would prevent one patient developing VAP. There was no evidence of a difference between interventions for the outcomes of mortality (RR 1.03, 95% CI 0.80 to 1.33; P = 0.86, I2 = 0%; 9 RCTs, 944 participants; moderate-certainty evidence), duration of mechanical ventilation (MD -1.10 days, 95% CI -3.20 to 1.00 days; P = 0.30, I2 = 74%; 4 RCTs, 594 participants; very low-certainty evidence) or duration of intensive care unit (ICU) stay (MD -0.89 days, 95% CI -3.59 to 1.82 days; P = 0.52, I2 = 69%; 5 RCTs, 627 participants; low-certainty evidence). Most studies did not mention adverse effects. One study reported adverse effects, which were mild, with similar frequency in CHX and control groups and one study reported there were no adverse effects. Toothbrushing (± antiseptics) may reduce the incidence of VAP (RR 0.61, 95% CI 0.41 to 0.91; P = 0.01, I2 = 40%; 5 RCTs, 910 participants; low-certainty evidence) compared to OHC without toothbrushing (± antiseptics). There is also some evidence that toothbrushing may reduce the duration of ICU stay (MD -1.89 days, 95% CI -3.52 to -0.27 days; P = 0.02, I2 = 0%; 3 RCTs, 749 participants), but this is very low certainty. Low-certainty evidence did not show a reduction in mortality (RR 0.84, 95% CI 0.67 to 1.05; P = 0.12, I2 = 0%; 5 RCTs, 910 participants) or duration of mechanical ventilation (MD -0.43, 95% CI -1.17 to 0.30; P = 0.25, I2 = 46%; 4 RCTs, 810 participants). AUTHORS' CONCLUSIONS Chlorhexidine mouthwash or gel, as part of OHC, probably reduces the incidence of developing ventilator-associated pneumonia (VAP) in critically ill patients from 26% to about 18%, when compared to placebo or usual care. We did not find a difference in mortality, duration of mechanical ventilation or duration of stay in the intensive care unit, although the evidence was low certainty. OHC including both antiseptics and toothbrushing may be more effective than OHC with antiseptics alone to reduce the incidence of VAP and the length of ICU stay, but, again, the evidence is low certainty. There is insufficient evidence to determine whether any of the interventions evaluated in the studies are associated with adverse effects.
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Affiliation(s)
- Tingting Zhao
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Xinyu Wu
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Qi Zhang
- Department of Oral Implantology, The Affiliated Stomatology Hospital, Zhejiang University School of Medicine, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Hangzhou, China
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Helen V Worthington
- Cochrane Oral Health, Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Fang Hua
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Centre for Evidence-Based Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
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Collins T, Plowright C, Gibson V, Stayt L, Clarke S, Caisley J, Watkins CH, Hodges E, Leaver G, Leyland S, McCready P, Millin S, Platten J, Scallon M, Tipene P, Wilcox G. British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units. Nurs Crit Care 2020; 26:224-233. [PMID: 33124119 DOI: 10.1111/nicc.12570] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Sarah Clarke
- Acute Care Team, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jo Caisley
- Princess Mary's Royal Air Force Nursing Service, UK
| | - Claire Harcourt Watkins
- Intensive Care, Glangwili General Hospital, Hywel Dda University Health Board, Haverfordwest, UK
| | - Emily Hodges
- The Queen Elizabeth Hospital NHS Foundation Trust, King's Lynn, UK
| | - Gillian Leaver
- Thames Valley and Wessex Operational Delivery Network, UK
| | - Sarah Leyland
- Clinical Placements, St Georges University Hospitals NHS Foundation Trust, UK
| | | | | | - Julie Platten
- North of England Critical Care Network, North Shields, UK
| | | | - Patsy Tipene
- The Queen Elizabeth Hospital NHS Foundation Trust, King's Lynn, UK
| | - Gabby Wilcox
- Swansea Bay University Health Board, Morriston Hospital, Swansea, UK
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Satheeshkumar PS, Papatheodorou S, Sonis S. Enhanced oral hygiene interventions as a risk mitigation strategy for the prevention of non-ventilator-associated pneumonia: a systematic review and meta-analysis. Br Dent J 2020; 228:615-622. [PMID: 32332964 PMCID: PMC7223037 DOI: 10.1038/s41415-020-1452-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background Healthcare-acquired pneumonias are a significant risk for nursing home and hospital patients. While oral care interventions (OCIs) have been found to be effective in reducing the risk of ventilator-associated pneumonia (VAP), their utility in mitigating non-ventilator-associated pneumonias (NVAP) remains unknown. We performed a structured meta-analysis of randomised and non-randomised clinical trials of enhanced oral hygiene procedures on NVAP.Methods We searched PubMed and Embase to include clinical trials (randomised and non-randomised), and observational (retrospective and prospective) and quasi-experimental studies examining the effect of any method of OCI on incidence of NVAP.Results After quality assessment and consensus agreement between authors, we synthesised six randomised clinical trials (3,891 patients), two non-randomised trials (2,993 patients), and separately assessed a retrospective trial (143 patients) and a quasi-experimental study (83 patients). Most studies, performed in nursing homes, did not show a significant association between OCI and NVAP prevention (RR random 0.89, 95% CI 0.64-1.25, p value 0.50). Likewise, the non-randomised trials failed to show an association between NVAP risk and OCI (RR random 1.42, 95% CI, 0.70-2.88, p value 0.32). However, in the subgroup analysis comparing dental professional involvement in care vs usual care, reduced NVAP risk was demonstrated (RR random 0.65, 95% CI 0.43-0.98, p value 0.03).Conclusions Study results suggest that professional dental care may confer some benefit among NVAP patients. The lack of consistent OCI protocols, data in hospitalised patients and robust randomised clinical trials do not allow definitive conclusions about the contribution of OCI in mitigating NVAP risk.
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Affiliation(s)
| | | | - Stephen Sonis
- Primary Endpoint Solutions, Watertown MA, USA; Brigham and Women's Hospital, Boston, MA, USA
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Jackson L, Owens M. Does oral care with chlorhexidine reduce ventilator-associated pneumonia in mechanically ventilated adults? ACTA ACUST UNITED AC 2019; 28:682-689. [PMID: 31188655 DOI: 10.12968/bjon.2019.28.11.682] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Oral colonisation by pathogens contributes to contracting ventilator-associated pneumonia (VAP). The aim of this review was to determine whether the use of the antiseptic chlorhexidine in the intra-oral cavity reduced its incidence in the critically ill, mechanically ventilated adult. The findings from this review led to the conclusion that chlorhexidine reduced the occurrence of VAP. Although a recommendation to implement the use of intra-oral chlorhexidine for mechanically-ventilated patients within critical care can be made, further exploration into required frequency and method of administration would be beneficial to reduce unnecessary exposure and hinder pathogenic resistance.
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Affiliation(s)
- Laura Jackson
- Nursing Sister, Neurosurgical Critical Care Ward L06/L07, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds
| | - Melissa Owens
- Lecturer, School of Nursing and Healthcare Leadership, Faculty of Health Studies, University of Bradford
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Oropharyngeal Bacterial Colonization after Chlorhexidine Mouthwash in Mechanically Ventilated Critically Ill Patients. Anesthesiology 2019; 129:1140-1148. [PMID: 30247201 DOI: 10.1097/aln.0000000000002451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Oropharyngeal care with chlorhexidine to prevent ventilator-associated pneumonia is currently questioned, and exhaustive microbiologic data assessing its efficacy are lacking. The authors therefore aimed to study the effect of chlorhexidine mouthwash on oropharyngeal bacterial growth, to determine chlorhexidine susceptibility of these bacteria, and to measure chlorhexidine salivary concentration after an oropharyngeal care. METHODS This observational, prospective, single-center study enrolled 30 critically ill patients under mechanical ventilation for over 48 h. Oropharyngeal contamination was assessed by swabbing the gingivobuccal sulcus immediately before applying 0.12% chlorhexidine with soaked swabs, and subsequently at 15, 60, 120, 240, and 360 min after. Bacterial growth and identification were performed, and chlorhexidine minimal inhibitory concentration of recovered pathogens was determined. Saliva was collected in 10 patients, at every timepoint, with an additional timepoint after 30 min, to measure chlorhexidine concentration. RESULTS Two hundred fifty bacterial samples were analyzed and identified 48 pathogens including Streptococci (27.1%) and Enterobacteriaceae (20.8%). Oropharyngeal contamination before chlorhexidine mouthwash ranged from 10 to 10 colony-forming units (CFU)/ml in the 30 patients (median contamination level: 2.5·10 CFU/ml), and remained between 8·10 (lowest) and 3·10 CFU/ml (highest count) after chlorhexidine exposure. These bacterial counts did not decrease overtime after chlorhexidine mouthwash (each minute increase in time resulted in a multiplication of bacterial count by a coefficient of 1.001, P = 0.83). Viridans group streptococci isolates had the lowest chlorhexidine minimal inhibitory concentration (4 [4 to 8] mg/l); Enterobacteriaceae isolates had the highest ones (32 [16 to 32] mg/l). Chlorhexidine salivary concentration rapidly decreased, reaching 7.6 [1.8 to 31] mg/l as early as 60 min after mouthwash. CONCLUSIONS Chlorhexidine oropharyngeal care does not seem to reduce bacterial oropharyngeal colonization in critically ill ventilated patients. Variable chlorhexidine minimal inhibitory concentrations along with low chlorhexidine salivary concentrations after mouthwash could explain this ineffectiveness, and thus question the use of chlorhexidine for ventilator-associated pneumonia prevention.
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de Camargo L, da Silva SN, Chambrone L. Efficacy of toothbrushing procedures performed in intensive care units in reducing the risk of ventilator-associated pneumonia: A systematic review. J Periodontal Res 2019; 54:601-611. [PMID: 31206663 DOI: 10.1111/jre.12668] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/15/2019] [Accepted: 05/01/2019] [Indexed: 11/28/2022]
Abstract
The aim of this systematic review (SR) was to assess whether toothbrushing-based oral heath measure (OHM), performed in intensive care units, can reduce the risk of ventilator-associated pneumonia (VAP). Dental biofilm removal has been considered important to prevent VAP. PUBMED, SCOPUS, WEB OF SCIENCE and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched up to and including December 2018 to identify randomized clinical trials (RCT) on the use of toothbrushing procedures in the prevention of VAP. Search was conducted by two independent reviewers. The risk of bias of each included study was assessed using the Cochrane Collaboration's domain-based, two-part tool. Random effects meta-analyses were conducted thoroughly. Search strategy identified 215 potentially eligible articles, of which 12 RCT were included. All studies evidenced the importance of OHM in mechanically ventilated patients in order to prevent VAP. Seven RCT (58.3%) found some degree of positive association between toothbrushing, alone or associated to oral topical chlorhexidine (CHX), and a potential reduction of mechanical ventilation-related outcomes and dental biofilm/oral bacteria. However, pooled estimates did not identify an additional decrease of VAP incidence for any of the tested procedures (ie, toothbrushing + CHX versus swab/gauze cleaning + CHX or toothbrushing + CHX versus toothbrushing alone or + placebo). Toothbrushing does not seem to promote a reduction of VAP-outcomes compared to swab/gauze cleaning, when topic CHX is applied for oral hygiene of patients submitted to mechanical ventilation.
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Affiliation(s)
- Luiz de Camargo
- MSc Dentistry Program, Ibirapuera University (Unib), São Paulo, Brazil
| | | | - Leandro Chambrone
- MSc Dentistry Program, Ibirapuera University (Unib), São Paulo, Brazil.,Unit of Basic Oral Investigation (UIBO), School of Dentistry, El Bosque University, Bogota, Colombia
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Aerodigestive sampling reveals altered microbial exchange between lung, oropharyngeal, and gastric microbiomes in children with impaired swallow function. PLoS One 2019; 14:e0216453. [PMID: 31107879 PMCID: PMC6527209 DOI: 10.1371/journal.pone.0216453] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 04/22/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Children with oropharyngeal dysphagia have impaired airway protection mechanisms and are at higher risk for pneumonia and other pulmonary complications. Aspiration of gastric contents is often implicated as a cause for these pulmonary complications, despite being supported by little evidence. The goal of this study is to determine the relative contribution of oropharyngeal and gastric microbial communities to perturbations in the lung microbiome of children with and without oropharyngeal dysphagia and aspiration. METHODS We conducted a prospective cohort study of 220 patients consecutively recruited from a tertiary aerodigestive center undergoing simultaneous esophagogastroduodenoscopy and flexible bronchoscopy. Bronchoalveolar lavage, gastric and oropharyngeal samples were collected from all recruited patients and 16S sequencing was performed. A subset of 104 patients also underwent video fluoroscopic swallow studies to assess swallow function and were categorized as aspiration/no aspiration. To ensure the validity of the results, we compared the microbiome of these aerodigestive patients to the microbiome of pediatric patients recruited to a longitudinal cohort study of children with suspected GERD; patients recruited to this study had oropharyngeal, gastric and/or stool samples available. The relationships between microbial communities across the aerodigestive tract were described by analyzing within- and between-patient beta diversities and identifying taxa which are exchanged between aerodigestive sites within patients. These relationships were then compared in patients with and without aspiration to evaluate the effect of aspiration on the aerodigestive microbiome. RESULTS Within all patients, lung, oropharyngeal and gastric microbiomes overlap. The degree of similarity is the lowest between the oropharynx and lungs (median Jensen-Shannon distance (JSD) = 0.90), and as high between the stomach and lungs as between the oropharynx and stomach (median JSD = 0.56 for both; p = 0.6). Unlike the oropharyngeal microbiome, lung and gastric communities are highly variable across people and driven primarily by person rather than body site. In patients with aspiration, the lung microbiome more closely resembles oropharyngeal rather than gastric communities and there is greater prevalence of microbial exchange between the lung and oropharynx than between gastric and lung sites (p = 0.04 and 4x10-5, respectively). CONCLUSIONS The gastric and lung microbiomes display significant overlap in patients with intact airway protective mechanisms while the lung and oropharynx remain distinct. In patients with impaired swallow function and aspiration, the lung microbiome shifts towards oropharyngeal rather than gastric communities. This finding may explain why antireflux surgeries fail to show benefit in pediatric pulmonary outcomes.
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Azab SRE, Sayed AEE, Abdelkarim M, Mutairi KBA, Saqabi AA, Demerdash SE. Combination of ventilator care bundle and regular oral care with chlorhexidine was associated with reduction in ventilator associated pneumonia. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Samia Ragab El Azab
- Specialist at king Fahd Hospital, Buryada, Saudi Arabia
- Anesthesia & Intensive Care, Al Azhar University , Cairo, Egypt
| | | | - Mutaz Abdelkarim
- Director of Informatics and CPD, Ayoun Aljawa Hospital , Saudi Arabia
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Dai R, Lam OLT, Lo ECM, Li LSW, McGrath C. Effect of oral hygiene programmes on oral opportunistic pathogens during stroke rehabilitation. Oral Dis 2018; 25:617-633. [PMID: 30447165 DOI: 10.1111/odi.13005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 10/28/2018] [Accepted: 11/11/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVES This study was to assess the effectiveness of a conventional oral hygiene care programme (COHCP) and an advanced oral hygiene care programme (AOHCP) on prevalence and viable counts of oral opportunistic pathogens among patients undergoing stroke rehabilitation. METHODS A total of 94 patients were randomized to two groups. Subjects were block randomized to either (a) COHCP: manual toothbrushing with oral hygiene instruction (OHI); or (b) AOHCP: powered toothbrushing, mouthrinsing with chlorhexidine and OHI. Prevalence and viable counts of oral opportunistic pathogens including yeasts, aerobic and facultative anaerobic gram-negative bacilli, Staphylococcus aureus, were assessed at baseline, the end of 3 and 6 months. RESULTS No significant difference was observed in the prevalence of oral opportunistic pathogens within each group over the clinical trial period. A significant decrease in the viable counts of S. aureus was found over the clinical trial period within AOHCP group (p < 0.05), while the viable counts of yeasts and anaerobic gram-negative bacillus (AGNB) remained stable within each group. Regression analysis failed to detect an association between intervention and the prevalence/viable counts of oral opportunistic pathogens. CONCLUSIONS Neither oral healthcare programme significantly affects AGNB, yeast or S. aureus over the study period in terms of prevalence and viable counts.
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Affiliation(s)
- Ruoxi Dai
- Dental Public Health, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong.,Key Laboratory of Oral Diseases Research of Anhui Province, Stomatologic Hospital & College, Anhui Medical University, Hefei, China
| | - Otto L T Lam
- Prosthodontics, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong
| | - Edward C M Lo
- Dental Public Health, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong
| | - Leonard S W Li
- Rehabilitation Medicine, Tung Wah Hospital, Hong Kong, Hong Kong
| | - Colman McGrath
- Dental Public Health, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong
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Liu C, Cao Y, Lin J, Ng L, Needleman I, Walsh T, Li C. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database Syst Rev 2018; 9:CD012416. [PMID: 30264525 PMCID: PMC6513285 DOI: 10.1002/14651858.cd012416.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pneumonia occurring in residents of long-term care facilities and nursing homes can be termed 'nursing home-acquired pneumonia' (NHAP). NHAP is the leading cause of mortality among residents. NHAP may be caused by aspiration of oropharyngeal flora into the lung, and by failure of the individual's defence mechanisms to eliminate the aspirated bacteria. Oral care measures to remove or disrupt oral plaque might be effective in reducing the risk of NHAP. OBJECTIVES To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 November 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 10), MEDLINE Ovid (1946 to 15 November 2017), and Embase Ovid (1980 to 15 November 2017) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1937 to 15 November 2017). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, and the Sciencepaper Online to 20 November 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous outcomes, mean difference (MD) for continuous outcomes, and hazard ratio (HR) for time-to-event outcomes, using random-effects models. MAIN RESULTS We included four RCTs (3905 participants), all of which were at high risk of bias. The studies all evaluated one comparison: professional oral care versus usual oral care. We did not pool the results from one study (N = 834 participants), which was stopped at interim analysis due to lack of a clear difference between groups.We were unable to determine whether professional oral care resulted in a lower incidence rate of NHAP compared with usual oral care over an 18-month period (hazard ratio 0.65, 95% CI 0.29 to 1.46; one study, 2513 participants analysed; low-quality evidence).We were also unable to determine whether professional oral care resulted in a lower number of first episodes of pneumonia compared with usual care over a 24-month period (RR 0.61, 95% CI 0.37 to 1.01; one study, 366 participants analysed; low-quality evidence).There was low-quality evidence from two studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24-month follow-up (RR 0.41, 95% CI 0.24 to 0.72, 507 participants analysed).We were uncertain whether or not professional oral care may reduce all-cause mortality compared to usual care, when measured at 24-month follow-up (RR 0.55, 95% CI 0.27 to 1.15; one study, 141 participants analysed; very low-quality evidence).Only one study (834 participants randomised) measured adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining.No studies evaluated oral care versus no oral care. AUTHORS' CONCLUSIONS Although low-quality evidence suggests that professional oral care could reduce mortality due to pneumonia in nursing home residents when compared to usual care, this finding must be considered with caution. Evidence for other outcomes is inconclusive. We found no high-quality evidence to determine which oral care measures are most effective for reducing nursing home-acquired pneumonia. Further trials are needed to draw reliable conclusions.
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Affiliation(s)
- Chang Liu
- West China Hospital of Stomatology, Sichuan UniversityDepartment of Oral and Maxillofacial Surgery, State Key Laboratory of Oral DiseasesNO.14, 3rd Section of Ren Min Nan RoadChengduSichuanChina610041
| | - Yubin Cao
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Jie Lin
- West China Hospital of Stomatology, Sichuan UniversityDepartment of Oral Anaesthesiology and Intensive Care UnitNo 14, Section 3, South Renmin RoadChengduSichuanChina610041
| | - Linda Ng
- The University of QueenslandSchool of Nursing and MidwiferyMater Campus: JP Kelly BuildingSouth BrisbaneQueenslandAustralia4101
| | - Ian Needleman
- UCL Eastman Dental InstituteUnit of Periodontology and International Centre for Evidence‐Based Oral Health256 Gray's Inn RoadLondonUKWC1X 8LD
| | - Tanya Walsh
- The University of ManchesterDivision of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
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Ab Malik N, Abdul Razak F, Mohamad Yatim S, Lam OLT, Jin L, Li LS, McGrath C. Oral Health Interventions Using Chlorhexidine—Effects on the Prevalence of Oral Opportunistic Pathogens in Stroke Survivors: A Randomized Clinical Trial. J Evid Based Dent Pract 2018; 18:99-109. [DOI: 10.1016/j.jebdp.2017.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 01/22/2023]
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Manger D, Walshaw M, Fitzgerald R, Doughty J, Wanyonyi KL, White S, Gallagher JE. Evidence summary: the relationship between oral health and pulmonary disease. Br Dent J 2018; 222:527-533. [PMID: 28387268 DOI: 10.1038/sj.bdj.2017.315] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 12/11/2022]
Abstract
Introduction This paper is the second of four reviews exploring the relationships between oral health and general medical conditions, in order to support teams within Public Health England, health practitioners and policymakers.Aim This review aimed to explore the most contemporary evidence on whether poor oral health and pulmonary disease occurs in the same individuals or populations, to outline the nature of the relationship between these two health outcomes, and discuss the implication of any findings for health services and future research.Methods The work was undertaken by a group comprising consultant clinicians from medicine and dentistry, trainees, public health, and academics. The methodology involved a streamlined rapid review process and synthesis of the data.Results The results identified a number of systematic reviews of medium to high quality which provide evidence that oral health and oral hygiene habits have an impact on incidence and outcomes of lung diseases, such as pneumonia and chronic obstructive pulmonary disease in people living in the community and in long-term care facilities. The findings are discussed in relation to the implications for service and future research.Conclusion The cumulative evidence of this review suggests an association between oral and pulmonary disease, specifically COPD and pneumonia, and incidence of the latter can be reduced by oral hygiene measures such as chlorhexidine and povidone iodine in all patients, while toothbrushing reduces the incidence, duration, and mortality from pneumonia in community and hospital patients.
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Affiliation(s)
- D Manger
- Specialist in Special Care Dentistry, Northamptonshire Healthcare NHS Foundation Trust, Salaried Primary Care Dental Service, Willowbrook Health Centre, Cottingham Road, Corby, NN17 2UR
| | - M Walshaw
- Department of Infection Microbiology and Immunology, Liverpool University and Consultant Chest Physician, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, L14 3PE
| | - R Fitzgerald
- Community Special Care Dentistry/Dental Public Health/Honorary Research Assistant
| | - J Doughty
- Special Care Dentistry, Northampton Healthcare NHS Foundation Trust, Academic Clinical Fellow in Special Care Dentistry, Eastman Dental Hospital, University College London, 256 Gray's Inn Road, London, WC1X 8LD
| | - K L Wanyonyi
- Dental Public Health, University of Portsmouth Dental Academy, William Beatty Building, Hampshire Terrace, Portsmouth PO1 2QG
| | - S White
- Population Health &Care Division, Health and Wellbeing Directorate, Public Health England, Skipton House, 80 London Road, London, SE1 6LH
| | - J E Gallagher
- Newland Pedley Professor of Oral Health Strategy, Honorary Consultant in Dental Public Health, King's College London Dental Institute, Denmark Hill Campus, Bessemer Road, London, SE5 9RS
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Unusually High Incidences of Staphylococcus aureus Infection within Studies of Ventilator Associated Pneumonia Prevention Using Topical Antibiotics: Benchmarking the Evidence Base. Microorganisms 2018; 6:microorganisms6010002. [PMID: 29300363 PMCID: PMC5874616 DOI: 10.3390/microorganisms6010002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/29/2017] [Accepted: 01/02/2018] [Indexed: 01/08/2023] Open
Abstract
Selective digestive decontamination (SDD, topical antibiotic regimens applied to the respiratory tract) appears effective for preventing ventilator associated pneumonia (VAP) in intensive care unit (ICU) patients. However, potential contextual effects of SDD on Staphylococcus aureus infections in the ICU remain unclear. The S. aureus ventilator associated pneumonia (S. aureus VAP), VAP overall and S. aureus bacteremia incidences within component (control and intervention) groups within 27 SDD studies were benchmarked against 115 observational groups. Component groups from 66 studies of various interventions other than SDD provided additional points of reference. In 27 SDD study control groups, the mean S. aureus VAP incidence is 9.6% (95% CI; 6.9–13.2) versus a benchmark derived from 115 observational groups being 4.8% (95% CI; 4.2–5.6). In nine SDD study control groups the mean S. aureus bacteremia incidence is 3.8% (95% CI; 2.1–5.7) versus a benchmark derived from 10 observational groups being 2.1% (95% CI; 1.1–4.1). The incidences of S. aureus VAP and S. aureus bacteremia within the control groups of SDD studies are each higher than literature derived benchmarks. Paradoxically, within the SDD intervention groups, the incidences of both S. aureus VAP and VAP overall are more similar to the benchmarks.
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Marjanovic N, Frasca D, Asehnoune K, Paugam C, Lasocki S, Ichai C, Lefrant JY, Leone M, Dahyot-Fizelier C, Pottecher J, Falcon D, Veber B, Constantin JM, Seguin S, Guénézan J, Mimoz O. Multicentre randomised controlled trial to investigate the usefulness of continuous pneumatic regulation of tracheal cuff pressure for reducing ventilator-associated pneumonia in mechanically ventilated severe trauma patients: the AGATE study protocol. BMJ Open 2017; 7:e017003. [PMID: 28790042 PMCID: PMC5724199 DOI: 10.1136/bmjopen-2017-017003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/17/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Severe trauma represents the leading cause of mortality worldwide. While 80% of deaths occur within the first 24 hours after trauma, 20% occur later and are mainly due to healthcare-associated infections, including ventilator-associated pneumonia (VAP). Preventing underinflation of the tracheal cuff is recommended to reduce microaspiration, which plays a major role in the pathogenesis of VAP. Automatic devices facilitate the regulation of tracheal cuff pressure, and their implementation has the potential to reduce VAP. The objective of this work is to determine whether continuous regulation of tracheal cuff pressure using a pneumatic device reduces the incidence of VAP compared with intermittent control in severe trauma patients. METHODS AND ANALYSIS This multicentre randomised controlled and open-label trial will include patients suffering from severe trauma who are admitted within the first 24 hours, who require invasive mechanical ventilation to longer than 48 hours. Their tracheal cuff pressure will be monitored either once every 8 hours (control group) or continuously using a pneumatic device (intervention group). The primary end point is the proportion of patients that develop VAP in the intensive care unit (ICU) at day 28. The secondary end points include the proportion of patients that develop VAP in the ICU, early (≤7 days) or late (>7 days) VAP, time until the first VAP diagnosis, the number of ventilator-free days and antibiotic-free days, the length of stay in the ICU, the proportion of patients with ventilator-associated events and that die during their ICU stay. ETHICS AND DISSEMINATION This protocol has been approved by the ethics committee of Poitiers University Hospital, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION Clinical Trials NCT02534974.
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Affiliation(s)
- Nicolas Marjanovic
- Department of Emergency and Prehospital Care, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Denis Frasca
- INSERM UMR1246—Methods in Patient-Centered Outcomes and Health Research, Poitiers, France
| | - Karim Asehnoune
- Centre Hospitalier Universitaire de Nantes, Anaesthesia and Intensive Care Unit, Nantes, France
| | - Catherine Paugam
- Assistance Publique des Hôpitaux de Paris, Intensive Care Unit, Hôpital Beaujon, Clichy, France
| | - Sigismond Lasocki
- Centre Hospitalier Universitaire d’Angers, Intensive Care Unit, Angers, France
| | - Carole Ichai
- Centre Hospitalier Universitaire de Nice, Intensive Care Unit, Nice, France
| | - Jean-Yves Lefrant
- Division Anaesthesia Critical Care, Emergency and Pain Medicine, Centre Hospitalier Universitaire de Nimes, Nimes, France
| | - Marc Leone
- Assistance Publique Hopitaux de Marseille, Intensive Care Unit, Hôpital Nord, Marseille, France
| | - Claire Dahyot-Fizelier
- Centre Hospitalier Universitaire de Poitiers, Neuro-Intensive Care Unit, Poitiers, France
| | - Julien Pottecher
- Hopitaux Universitaires de Strasbourg, Intensive Care Unit, Strasbourg, France
| | - Dominique Falcon
- Centre Hospitalier Universitaire de Grenoble, Intensive Care Unit, Grenoble, France
| | - Benoit Veber
- Centre Hospitalier Universitaire de Rouen, Intensive Care Unit, Rouen, France
| | - Jean-Michel Constantin
- Centre Hospitalier Universitaire de Clermont-Ferrand, Intensive Care Unit, Clermont-Ferrand, France
| | - Sabrina Seguin
- Department of Emergency and Prehospital Care, Centre Hospitalier Universitaire de Poitiers, Intensive Care Unit, Poitiers, France
| | - Jérémy Guénézan
- Department of Emergency and Prehospital Care, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Olivier Mimoz
- Department of Emergency and Prehospital Care, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- INSERM U1070, Université de Poitiers, Poitiers, France
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Zand F, Zahed L, Mansouri P, Dehghanrad F, Bahrani M, Ghorbani M. The effects of oral rinse with 0.2% and 2% chlorhexidine on oropharyngeal colonization and ventilator associated pneumonia in adults' intensive care units. J Crit Care 2017; 40:318-322. [PMID: 28320561 DOI: 10.1016/j.jcrc.2017.02.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/08/2017] [Accepted: 02/19/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ventilator Associated Pneumonia (VAP) is the most common nosocomial infection in Intensive Care Units (ICUs) which increases the length of ICU stay, duration of mechanical ventilation, and mortality. The present study used an oral care protocol and compared the effects of two different concentrations of chlorhexidine on reduction of oropharyngeal colonization and VAP. MATERIALS AND METHODS This study was performed on 114 patients from trauma, surgery, neurosurgery, and general ICUs randomly allocated to two groups under oral care with 0.2% and 2% chlorhexidine solution. A multidisciplinary team approved the oral care protocol. Data was collected using a demographic information form, APACHE IV form, Beck oral assessment scale, mucosal-plaque assessment scale, and oropharyngeal swab culture. RESULTS The results showed a significant reduction in VAP (p=0.007) and oropharyngeal colonization (p=0.007) in the group under oral care with 2% chlorhexidine solution compared with the other group. However, no significant difference was found between the two groups in terms of oropharyngeal adverse effects (p=0.361). CONCLUSION Oral decontamination with 2% compared to 0.2% chlorhexidine is a more effective method in the prevention of VAP and reduction of oropharyngeal colonization (especially gram-positive).
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Affiliation(s)
- Farid Zand
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leili Zahed
- Fatemeh Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parisa Mansouri
- Fatemeh Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Freshte Dehghanrad
- Fatemeh Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Bahrani
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Ghorbani
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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de Castro LA, de Castro JGL, de Alcantara JS, Garcia Junior DA, Romeu CSN, Coutinho IHILS. Why Physicians Should Look at the Mouths of Their Patients. J Clin Med Res 2016; 8:841-843. [PMID: 27829947 PMCID: PMC5087621 DOI: 10.14740/jocmr2735w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 01/22/2023] Open
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Hua F, Xie H, Worthington HV, Furness S, Zhang Q, Li C. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev 2016; 10:CD008367. [PMID: 27778318 PMCID: PMC6460950 DOI: 10.1002/14651858.cd008367.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in people who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions, may reduce the risk of VAP in these patients. OBJECTIVES To assess the effects of oral hygiene care on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs). SEARCH METHODS We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 17 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 11), MEDLINE Ovid (1946 to 17 December 2015), Embase Ovid (1980 to 17 December 2015), LILACS BIREME Virtual Health Library (1982 to 17 December 2015), CINAHL EBSCO (1937 to 17 December 2016), Chinese Biomedical Literature Database (1978 to 14 January 2013), China National Knowledge Infrastructure (1994 to 14 January 2013), Wan Fang Database (January 1984 to 14 January 2013) and VIP Database (January 2012 to 4 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 17 December 2015. We placed no restrictions on the language or date of publication when searching the electronic databases. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data and assessed risk of bias in included studies. We contacted study authors for additional information. We pooled data from trials with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, using random-effects models unless there were fewer than four studies. MAIN RESULTS We included 38 RCTs (6016 participants). There were four main comparisons: chlorhexidine (CHX) mouthrinse or gel versus placebo/usual care; toothbrushing versus no toothbrushing; powered versus manual toothbrushing; and comparisons of oral care solutions. We assessed the overall risk of bias as low in five trials (13%), high in 26 trials (68%), and unclear in seven trials (18%). We did not consider the risk of bias to be serious when assessing the quality of evidence (GRADE) for VAP incidence, but we downgraded other outcomes for risk of bias.High quality evidence from 18 RCTs (2451 participants, 86% adults) shows that CHX mouthrinse or gel, as part of OHC, reduces the risk of VAP compared to placebo or usual care from 25% to about 19% (RR 0.74, 95% confidence intervals (CI) 0.61 to 0.89, P = 0.002, I2 = 31%). This is equivalent to a number needed to treat for an additional beneficial outcome (NNTB) of 17 (95% CI 10 to 33), which indicates that for every 17 ventilated patients in intensive care receiving OHC including chlorhexidine, one outcome of VAP would be prevented. There is no evidence of a difference between CHX and placebo/usual care for the outcomes of mortality (RR 1.09, 95% CI 0.96 to 1.23, P = 0.18, I2 = 0%, 15 RCTs, 2163 participants, moderate quality evidence), duration of mechanical ventilation (MD -0.09 days, 95% CI -1.73 to 1.55 days, P = 0.91, I2 = 36%, five RCTs, 800 participants, low quality evidence), or duration of intensive care unit (ICU) stay (MD 0.21 days, 95% CI -1.48 to 1.89 days, P = 0.81, I2 = 9%, six RCTs, 833 participants, moderate quality evidence). There is insufficient evidence to determine the effect of CHX on duration of systemic antibiotics, oral health indices, caregivers' preferences or cost. Only two studies reported any adverse effects, and these were mild with similar frequency in CHX and control groups.We are uncertain as to the effects of toothbrushing (± antiseptics) on the outcomes of VAP (RR 0.69, 95% CI 0.44 to 1.09, P = 0.11, I2 = 64%, five RCTs, 889 participants, very low quality evidence) and mortality (RR 0.87, 95% CI 0.70 to 1.09, P = 0.24, I2 = 0%, five RCTs, 889 participants, low quality evidence) compared to OHC without toothbrushing (± antiseptics). There is insufficient evidence to determine whether toothbrushing affects duration of mechanical ventilation, duration of ICU stay, use of systemic antibiotics, oral health indices, adverse effects, caregivers' preferences or cost.Only one trial (78 participants) compared use of a powered toothbrush with a manual toothbrush, providing insufficient evidence to determine the effect on any of the outcomes of this review.Fifteen trials compared various other oral care solutions. There is very weak evidence that povidone iodine mouthrinse is more effective than saline/placebo (RR 0.69, 95% CI 0.50 to 0.95, P = 0.02, I2 = 74%, three studies, 356 participants, high risk of bias), and that saline rinse is more effective than saline swab (RR 0.47, 95% CI 0.37 to 0.62, P < 0.001, I2 = 84%, four studies, 488 participants, high risk of bias) in reducing VAP. Due to variation in comparisons and outcomes among trials, there is insufficient evidence concerning the effects of other oral care solutions. AUTHORS' CONCLUSIONS OHC including chlorhexidine mouthwash or gel reduces the risk of developing ventilator-associated pneumonia in critically ill patients from 25% to about 19%. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There is no evidence that OHC including both antiseptics and toothbrushing is different from OHC with antiseptics alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline/placebo, and saline rinse is more effective than saline swab in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP. There is also insufficient evidence to determine whether any of the interventions evaluated in the studies are associated with adverse effects.
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Affiliation(s)
- Fang Hua
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthOxford RoadManchesterUKM13 9PL
| | - Huixu Xie
- West China College of Stomatology, Sichuan UniversityDepartment of Oral and Maxillofacial Surgery, State Key Laboratory of Oral DiseasesNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthOxford RoadManchesterUKM13 9PL
| | - Susan Furness
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthOxford RoadManchesterUKM13 9PL
| | - Qi Zhang
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan UniversityDepartment of Oral ImplantologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
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Prospective observational study to compare oral topical metronidazole versus 0.2% chlorhexidine gluconate to prevent nosocomial pneumonia. Am J Infect Control 2016; 44:1116-1122. [PMID: 27317405 DOI: 10.1016/j.ajic.2016.03.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/08/2016] [Accepted: 03/08/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Nosocomial pneumonia is one of the most common health care-associated infections in intensive care units (ICUs) worldwide, attributing to high morbidity and mortality. Our study aim is to investigate the effectiveness of oral hygiene with 0.2% chlorhexidine gluconate (CHX) and 0.08% metronidazole (MDE) influencing the microbiologic epidemiology and incidence of nonintubation pneumonia (NIP) and ventilator-associated pneumonia (VAP). METHODS Patients who stayed >48 hours in the emergency ICU between 2008 and 2012 were enrolled and provided oral hygiene by swabbing with 0.08% MDE twice daily until discharge or death during the first year (period M), whereas CHX was applied during the following 3 years (period C). The incidence and microbiologic epidemiology of NIP and VAP were studied. RESULTS There were 873 patients enrolled. There were 44 episodes of NIP and 25 episodes of VAP that occurred among 212 patients in period M, and 84 episodes of NIP and 49 episodes of VAP occurred among 661 patients in period C. Overall, the rate of NIP and VAP decreased year by year. Acinetobacter baumannii was the most frequently identified bacteria for NIP (22.9%) and VAP (25.3%), with an annual ascent. Few changes were observed on bacteria distribution for NIP and VAP. CONCLUSIONS Oral hygiene with CHX, having reduced the incidence of nosocomial pneumonia among critical ill patients, suggests a benefit of oral hygiene in decreasing the incidence of nosocomial pneumonia, including VAP in ICUs, but not bacterial epidemiology.
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Saensom D, Merchant AT, Wara-Aswapati N, Ruaisungnoen W, Pitiphat W. Oral health and ventilator-associated pneumonia among critically ill patients: a prospective study. Oral Dis 2016; 22:709-14. [PMID: 27388365 DOI: 10.1111/odi.12535] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/14/2016] [Accepted: 07/03/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the association between oral health and ventilator-associated pneumonia (VAP) among critically ill patients. METHODS A prospective cohort study was conducted among 162 critically ill patients newly intubated and treated with mechanical ventilator in one tertiary hospital in Thailand. Oral health status was assessed using Oral Health Assessment Tool (OHAT), Plaque Index (PI), and number of teeth. VAP, defined as Clinical Pulmonary Infection Score >6, was assessed on Day 4 after intubation. Hazard ratios and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression adjusted for confounders. RESULTS Critically ill patients had deteriorating oral health status after intubation. Early-onset VAP developed in 69 patients (42.6%), with VAP incidence of 117 episodes per 1000 ventilator-days. Moderately unhealthy and unhealthy oral conditions based on OHAT scores were associated with a 2.92-fold (95% CI: 1.26-6.74) and 3.22-fold (95% CI: 1.34-7.76) increased risk of VAP. Patients with moderate-to-very poor oral hygiene assessed by PI had increased VAP risk of 1.66-folds (95% CI: 1.001-2.75). The number of teeth was not associated with VAP development. CONCLUSIONS There is a strong association between poor oral health and increased risk for early-onset VAP. Routine oral care possibly prevents VAP development among critically ill patients treated with mechanical ventilator.
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Affiliation(s)
- D Saensom
- Graduate School, Khon Kean University, Khon Kaen, Thailand.,Faculty of Nursing, Khon Kean University, Khon Kaen, Thailand
| | - A T Merchant
- School of Public Health, University of South Carolina, Columbia, SC, USA
| | - N Wara-Aswapati
- Faculty of Dentistry, Khon Kean University, Khon Kaen, Thailand.,Chronic Inflammatory and Systemic Diseases Associated with Oral Health Research Group, Khon Kean University, Khon Kaen, Thailand
| | - W Ruaisungnoen
- Faculty of Nursing, Khon Kean University, Khon Kaen, Thailand
| | - W Pitiphat
- Faculty of Dentistry, Khon Kean University, Khon Kaen, Thailand. .,Chronic Inflammatory and Systemic Diseases Associated with Oral Health Research Group, Khon Kean University, Khon Kaen, Thailand.
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Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 2016; 35:915-36. [DOI: 10.1086/677144] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Sharif-Abdullah SSB, Chong MC, Surindar-Kaur SS, Kamaruzzaman SB, Ng KH. The effect of chlorhexidine in reducing oral colonisation in geriatric patients: a randomised controlled trial. Singapore Med J 2016; 57:262-6. [PMID: 27211885 PMCID: PMC4876416 DOI: 10.11622/smedj.2016091] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Inadequate oral care has been implicated in the development of aspiration pneumonia in frail geriatric patients and is a major cause of mortality, due to the colonisation of microbes in vulnerable patients. This type of pneumonia has been associated with an increase in respiratory pathogens in the oral cavity. The aim of this study was to evaluate the effects of chlorhexidine compared to routine oral care in edentulous geriatric inpatients. METHODS A double-blind, parallel-group randomised controlled trial was carried out. The intervention group received oral care with chlorhexidine 0.2%, while the control group received routine oral care with thymol. Nurses provided oral care with assigned solutions of 20 mL once daily over seven days. Oral cavity assessment using the Brief Oral Health Status Examination form was performed before each oral care procedure. Data on medication received and the subsequent development of aspiration pneumonia was recorded. An oral swab was performed on Day 7 to obtain specimens to test for colonisation. RESULTS The final sample consisted of 35 (control) and 43 (intervention) patients. Chlorhexidine was effective in reducing oral colonisation compared to routine oral care with thymol (p < 0.001). The risk of oral bacterial colonisation was nearly three times higher in the thymol group compared to the chlorhexidine group. CONCLUSION The use of chlorhexidine 0.2% significantly reduced oral colonisation and is recommended as an easier and more cost-effective alternative for oral hygiene.
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Affiliation(s)
- Sharifah Shafinaz Binti Sharif-Abdullah
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Nursing, Faculty of Health Science, Universiti Teknologi MARA, Puncak Alam Campus, Selangor, Malaysia
| | - Mei Chan Chong
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | | | - Kwan Hoong Ng
- Department of Biomedical Imaging & University of Malaya Research Imaging Centre, University of Malaya, Kuala Lumpur, Malaysia
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Trouillet JL, Luyt CE, Brechot N, Chastre J. Intérêt des soins de bouche et du brossage des dents dans la prévention des pneumonies acquises sous ventilation mécanique. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Meinberg MCDA, Cheade MDFM, Miranda ALD, Fachini MM, Lobo SM. The use of 2% chlorhexidine gel and toothbrushing for oral hygiene of patients receiving mechanical ventilation: effects on ventilator-associated pneumonia. Rev Bras Ter Intensiva 2015; 24:369-74. [PMID: 23917935 PMCID: PMC4031818 DOI: 10.1590/s0103-507x2012000400013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 09/28/2012] [Indexed: 11/21/2022] Open
Abstract
Objective To evaluate the effects of oral chlorhexidine hygiene with toothbrushing on the
rate of ventilator-associated pneumonia in a mixed population of critically ill
patients under prolonged mechanical ventilation. Methods Prospective, randomized, and placebo-controlled pilot study. Patients who were
receiving mechanical ventilation, had been admitted less than 24 hours prior, and
were anticipated to require mechanical ventilation for more than 72 hours were
included in the study. The patients were randomly divided into one of the
following groups: chlorhexidine hygiene with toothbrushing or a placebo group (gel
with the same color and consistency and toothbrushing). Results The planned interim analysis was conducted using 52 patients, and the study was
terminated prematurely. In total, 28 patients were included in the chlorhexidine /
toothbrushing group, and 24 patients were included in the placebo group.
Ventilator-associated pneumonia occurred in 45.8% of the placebo group and in
64.3% of the chlorhexidine hygiene with toothbrushing group (RR=1.4; 95%
CI=0.83-2.34; p=0.29). Conclusion Because the study was terminated due to futility, it was not possible to evaluate
the impact of oral hygiene using 2% chlorhexidine and toothbrushing on the
incidence of ventilator-associated pneumonia in this heterogeneous population of
critical patients receiving long-term mechanical ventilation, and no beneficial
effect was observed for this intervention.
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Thamlikitkul V, Rattanaumpawan P, Boonyasiri A, Pumsuwan V, Judaeng T, Tiengrim S, Paveenkittiporn W, Rojanasthien S, Jaroenpoj S, Issaracharnvanich S. Thailand Antimicrobial Resistance Containment and Prevention Program. J Glob Antimicrob Resist 2015; 3:290-294. [PMID: 27842876 DOI: 10.1016/j.jgar.2015.09.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/29/2015] [Accepted: 09/13/2015] [Indexed: 12/01/2022] Open
Abstract
The Thailand Antimicrobial Resistance (AMR) Containment and Prevention Program was founded to develop, co-ordinate and implement AMR Containment and Prevention (AMRCP) operational actions in Thailand following the 'One Health' approach. This article summarises the ten AMRCP operational actions initiated during the initial phase of the programme from 2012 to 2016: estimating the national AMR burden; establishing the dynamics of AMR chains to understand how AMR in Thailand develops and spreads; developing a national AMRCP infrastructure; developing laboratory and information technology systems for surveillance of AMR, antibiotic use and hospital-acquired infections; regulating the use and distribution of antibiotics in humans and food animals; generating local evidence for promoting responsible use of antibiotics and efficient practices for infection prevention and control; designing AMRCP campaigns; creating an AMRCP package; implementing the AMRCP package in selected pilot communities; and conducting research and development on diagnostics, therapy and prevention of antimicrobial-resistant bacterial infections. The programme's core campaign is to stop producing AMR by promoting responsible use of antibiotics, and to stop the acquisition and transmission of AMR by promoting good sanitation and hygiene as well as compliance with infection control and prevention practices.
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Affiliation(s)
- Visanu Thamlikitkul
- Faculty of Medicine Siriraj Hospital and Faculty of Medical Technology, Mahidol University, 2 Wang Lung Road, Bangkok, 10700, Thailand.
| | - Pinyo Rattanaumpawan
- Faculty of Medicine Siriraj Hospital and Faculty of Medical Technology, Mahidol University, 2 Wang Lung Road, Bangkok, 10700, Thailand
| | - Adhiratha Boonyasiri
- Faculty of Medicine Siriraj Hospital and Faculty of Medical Technology, Mahidol University, 2 Wang Lung Road, Bangkok, 10700, Thailand
| | - Varaporn Pumsuwan
- Faculty of Medicine Siriraj Hospital and Faculty of Medical Technology, Mahidol University, 2 Wang Lung Road, Bangkok, 10700, Thailand
| | - Tepnimitr Judaeng
- Faculty of Medicine Siriraj Hospital and Faculty of Medical Technology, Mahidol University, 2 Wang Lung Road, Bangkok, 10700, Thailand
| | - Surapee Tiengrim
- Faculty of Medicine Siriraj Hospital and Faculty of Medical Technology, Mahidol University, 2 Wang Lung Road, Bangkok, 10700, Thailand
| | | | | | - Sasi Jaroenpoj
- Department of Livestock Development, Ministry of Agriculture and Cooperatives, Bangkok, Thailand
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Vilela MCN, Ferreira GZ, Santos PSDS, Rezende NPMD. Oral care and nosocomial pneumonia: a systematic review. ACTA ACUST UNITED AC 2015; 13:290-6. [PMID: 25946053 PMCID: PMC4943826 DOI: 10.1590/s1679-45082015rw2980] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 07/21/2014] [Indexed: 11/21/2022]
Abstract
To perform a systematic review of the literature on the control of oral biofilms and the incidence of nosocomial pneumonia, in addition to assessing and classifying studies as to the grade of recommendation and level of evidence. The review was based on PubMed, LILACS, and Scopus databases, from January 1st, 2000 until December 31st, 2012. Studies evaluating oral hygiene care related to nosocomial infections in patients hospitalized in intensive care units were selected according to the inclusion criteria. Full published articles available in English, Spanish, or Portuguese, which approached chemical or mechanical oral hygiene techniques in preventing pneumonia, interventions performed, and their results were included. After analysis, the articles were classified according to level of evidence and grade of recommendation according to the criteria of the Oxford Centre for Evidence-Based Medicine. A total of 297 abstracts were found, 14 of which were full articles that met our criteria. Most articles included a study group with chlorhexidine users and a control group with placebo users for oral hygiene in the prevention of pneumonia. All articles were classified as B in the level of evidence, and 12 articles were classified as 2B and two articles as 2C in grade of recommendation. It was observed that the control of oral biofilm reduces the incidence of nosocomial pneumonia, but the fact that most articles had an intermediate grade of recommendation makes clear the need to conduct randomized controlled trials with minimal bias to establish future guidelines for oral hygiene in intensive care units.
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Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2015; 35 Suppl 2:S133-54. [PMID: 25376073 DOI: 10.1017/s0899823x00193894] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Abstract
Evidence based care (EBP) is imperative to the promotion of best practices. EBP forms the foundation for safe, efficient, and cost-effective patient management. It gives nurses the ability to implement care activities with proved outcomes and validate interventions from a database of sources. EBP not only has an impact on nursing practice but also affects theoretic models and care frameworks. It forms a foundation for professional care activities that use grounded protocols and guidelines and nursing education. This article includes resources to promote continued use of research evidence to guide in patient care areas.
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Affiliation(s)
- Maria A Revell
- Division of Nursing, Tennessee State University, 214 Jon Paul Court, Murfreesboro, TN 37128, USA.
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41
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Ataee RA. To: The use of 2% chlorhexidine gel and toothbrushing for oral hygiene of patients receiving mechanical ventilation: effects on ventilator-associated pneumonia. Rev Bras Ter Intensiva 2015; 26:438-9. [PMID: 25607277 PMCID: PMC4304476 DOI: 10.5935/0103-507x.20140068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ramezan Ali Ataee
- Department of Medical Microbiology, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Bellissimo-Rodrigues WT, Menegueti MG, Gaspar GG, Nicolini EA, Auxiliadora-Martins M, Basile-Filho A, Martinez R, Bellissimo-Rodrigues F. Effectiveness of a Dental Care Intervention in the Prevention of Lower Respiratory Tract Nosocomial Infections among Intensive Care Patients: A Randomized Clinical Trial. Infect Control Hosp Epidemiol 2015. [DOI: 10.1086/591478] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective.To evaluate whether dental treatment may enhance oral antisepsis, thus preventing more effectively lower respiratory tract infections (LRTIs) among critically ill patientsDesign.Observer-blind randomized clinical trial.Setting.General intensive care unit (ICU) for adult patients.Patients.We analyzed data from 254 adult patients who stayed for at least 48 hours in the ICU.Intervention.Patients were randomized by means of rolling dice. The experimental group (n= 127) had access to dental care provided by a dental surgeon, 4–5 times a week. Besides routine oral hygiene, care also included teeth brushing, tongue scraping, removal of calculus, atraumatic restorative treatment of caries, and tooth extraction. The control group (n= 127) had access to routine oral hygiene only, which included the use of chlorhexidine as a mouth rinse, which was performed by the ICU nurse staff.Results.The primary study outcome was the LRTI incidence, which was 8.7% in the experimental group and 18.1% in the control group (adjusted relative risk [RR], 0.44 [95% confidence interval (CI), 0.20–0.96];P= .04). Ventilator-associated pneumonia rates per 1,000 ventilator-days were 16.5 (95% CI, 9.8–29.5) in the control group and 7.6 (95% CI, 3.3–15.0) in the experimental group (P< .05). Mortality rates were similar between both study groups: 31.5% in the control group versus 29.1% in the experimental group (adjusted RR, 0.93 [95% CI, 0.52–1.65];P= .796). No severe adverse events related to oral care were observed during the study.Conclusion.Dental treatment was safe and effective in the prevention of LRTI among critically ill patients who were expected to stay at least 48 hours in the ICU.Trial registration.Brazilian Clinical Trials Registry, affiliated with the World Health Organization’s International Clinical Trial Registry Platform: U1111-1152-2671.Infect Control Hosp Epidemiol2014;35(11):1342–1348
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Panchabhai TS, Dangayach NS. Oral Cleansing with Chlorhexidine to Decrease the Incidence of Nosocomial Pneumonia: Using the Right Concentration in the Right Place. Infect Control Hosp Epidemiol 2015; 31:429; author reply 429-30. [DOI: 10.1086/651307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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44
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El-Rabbany M, Zaghlol N, Bhandari M, Azarpazhooh A. Prophylactic oral health procedures to prevent hospital-acquired and ventilator-associated pneumonia: A systematic review. Int J Nurs Stud 2015; 52:452-64. [DOI: 10.1016/j.ijnurstu.2014.07.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 07/16/2014] [Accepted: 07/18/2014] [Indexed: 01/16/2023]
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46
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Saddki N, Mohamad Sani FE, Tin-Oo MM. Oral care for intubated patients: a survey of intensive care unit nurses. Nurs Crit Care 2014; 22:89-98. [PMID: 25349099 DOI: 10.1111/nicc.12119] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 03/05/2014] [Accepted: 06/18/2014] [Indexed: 12/28/2022]
Abstract
AIMS This study aimed to determine attitudes and practices of intensive care unit (ICU) nurses towards provision of oral care for intubated patients. BACKGROUND Oral care is as an essential nursing intervention for intubated patients to maintain patient comfort and prevent colonization of dental plaque by respiratory pathogens. DESIGN This was a cross-sectional study. METHODS Data were collected from 93 ICU nurses of a teaching hospital in the East Coast of Peninsular Malaysia using a self-administered questionnaire. RESULTS Some nurses agreed that oral cavity of intubated patients was difficult (40·8%) and unpleasant (16·2%) to clean, but all of them realized the importance of oral care and the majority (97·9%) would like to learn more about it. Most nurses reported providing oral care at least two times daily using various methods and products such as suction toothbrush (90·4%), manual toothbrush (49·5%), cotton swab (91·5%) and foam swab (65·7%). Chlorhexidine gluconate oral rinse was the preferred mouthwash (97·8%) and swabs (93·5%) solution although few used non-optimal products such as sodium bicarbonate (14·0%), tap water (4·3%) and hydrogen peroxide (3·2%) to wash their patients' mouths. While the majority of nurses agreed that oral care supplies and equipments were available (93·6%) and suitable (88·2%), most of them also thought they need better hospital support (88·2%). CONCLUSIONS The nurses' attitudes towards oral care were generally positive and most oral care methods were appropriate. However, some methods and products used were inconsistent with the current recommendations and they have mixed views about the suitability of oral care supplies and equipment provided by the hospital. RELEVANCE TO CLINICAL PRACTICE Recommendations were made for providing standard oral care protocols for intubated patients and oral care training programs for ICU nurses to support delivery of quality patient care.
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Affiliation(s)
- Norkhafizah Saddki
- School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | | | - Mon Mon Tin-Oo
- School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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47
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Bellissimo-Rodrigues WT, Menegueti MG, Gaspar GG, Nicolini EA, Auxiliadora-Martins M, Basile-Filho A, Martinez R, Bellissimo-Rodrigues F. Effectiveness of a dental care intervention in the prevention of lower respiratory tract nosocomial infections among intensive care patients: a randomized clinical trial. Infect Control Hosp Epidemiol 2014; 35:1342-8. [PMID: 25333428 DOI: 10.1086/678427] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate whether dental treatment may enhance oral antisepsis, thus preventing more effectively lower respiratory tract infections (LRTIs) among critically ill patients. DESIGN Observer-blind randomized clinical trial. SETTING General intensive care unit (ICU) for adult patients. PATIENTS We analyzed data from 254 adult patients who stayed for at least 48 hours in the ICU. INTERVENTION Patients were randomized by means of rolling dice. The experimental group (n = 127) had access to dental care provided by a dental surgeon, 4-5 times a week. Besides routine oral hygiene, care also included teeth brushing, tongue scraping, removal of calculus, atraumatic restorative treatment of caries, and tooth extraction. The control group (n = 127) had access to routine oral hygiene only, which included the use of chlorhexidine as a mouth rinse, which was performed by the ICU nurse staff. RESULTS The primary study outcome was the LRTI incidence, which was 8.7% in the experimental group and 18.1% in the control group (adjusted relative risk [RR], 0.44 [95% confidence interval (CI), 0.20-0.96]; P = .04). Ventilator-associated pneumonia rates per 1,000 ventilator-days were 16.5 (95% CI, 9.8-29.5) in the control group and 7.6 (95% CI, 3.3-15.0) in the experimental group (P < .05). Mortality rates were similar between both study groups: 31.5% in the control group versus 29.1% in the experimental group (adjusted RR, 0.93 [95% CI, 0.52-1.65]; P = .796). No severe adverse events related to oral care were observed during the study. CONCLUSION Dental treatment was safe and effective in the prevention of LRTI among critically ill patients who were expected to stay at least 48 hours in the ICU. TRIAL REGISTRATION Brazilian Clinical Trials Registry, affiliated with the World Health Organization's International Clinical Trial Registry Platform: U1111-1152-2671.
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Affiliation(s)
- Wanessa T Bellissimo-Rodrigues
- Infectious Diseases Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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Factors related to compliance among critical care nurses with performing oral care protocols for mechanically ventilated patients in the intensive care unit. Am J Infect Control 2014; 42:533-5. [PMID: 24773790 DOI: 10.1016/j.ajic.2014.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 01/23/2014] [Accepted: 01/23/2014] [Indexed: 11/21/2022]
Abstract
Oral care is an important component of the ventilator bundle; however, few studies have investigated the factors related to compliance with performing oral care among critical care nurses. In this observational study of 759 oral care opportunities performed by 133 critical care nurses, we found that the overall oral care compliance rate was 83.3%. Multivariate analysis revealed that nurses' age, academic degree, intensive care unit license, and location were independent predictors of performing oral care for patients in the intensive care unit.
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49
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Qu X, Xie H, Zhang Q, Zhou X, Shi Z. A survey on oral care practices for ventilator-assisted patients in intensive care units in 3A hospitals of mainland China. Int J Nurs Pract 2014; 21:699-708. [PMID: 24689526 DOI: 10.1111/ijn.12282] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Oral hygiene is a critical element of patient care, particularly among patients who need ventilator-assisted equipment. The objective of this study was to explore the current status of oral care practices, attitudes, education and knowledge among intensive care unit (ICU) nurses caring for ventilator-assisted patients in 3A hospitals in mainland China. To achieve this aim, an 18-item self-assessment questionnaire was mailed to head ICU nurses in 189 Grade 3A hospitals. Additional data were collected through in-person interviews at 38 ICUs throughout Sichuan, Shanxi, Jiangsu provinces, as well as Chongqing and Beijing. We found that most ICUs conducted oral examinations at patient admission, and that this care was largely provided by nurses. The most common oral care methods were foam swabs and mouth rinse containing antibiotics or disinfectants. Although the majority of ICUs provided continuing training for oral care, and most training was conducted by head nurses, the content and scope of training were not consistent among the hospitals in the study. The most popular sources of oral care knowledge were academic journals, Internet and professional books. Overall, it is clear that an evidence-based oral care standard manual is urgently needed for oral practice in ICUs in mainland China.
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Affiliation(s)
- Xing Qu
- Hospital Management Department, School of Business, Sichuan University, Chengdu, Sichuan, China.,West China Hospital of Stomatology, Chengdu, Sichuan, China
| | - Huixu Xie
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Qi Zhang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Xuedong Zhou
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Zongdao Shi
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
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50
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Price R, MacLennan G, Glen J. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. BMJ 2014; 348:g2197. [PMID: 24687313 PMCID: PMC3970764 DOI: 10.1136/bmj.g2197] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2014] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine the effect on mortality of selective digestive decontamination, selective oropharyngeal decontamination, and topical oropharyngeal chlorhexidine in adult patients in general intensive care units and to compare these interventions with each other in a network meta-analysis. DESIGN Systematic review, conventional meta-analysis, and network meta-analysis. Medline, Embase, and CENTRAL were searched to December 2012. Previous meta-analyses, conference abstracts, and key journals were also searched. We used pairwise meta-analyses to estimate direct evidence from intervention-control trials and a network meta-analysis within a Bayesian framework to combine direct and indirect evidence. INCLUSION CRITERIA Prospective randomised controlled trials that recruited adult patients in general intensive care units and studied selective digestive decontamination, selective oropharyngeal decontamination, or oropharyngeal chlorhexidine compared with standard care or placebo. RESULTS Selective digestive decontamination had a favourable effect on mortality, with a direct evidence odds ratio of 0.73 (95% confidence interval 0.64 to 0.84). The direct evidence odds ratio for selective oropharyngeal decontamination was 0.85 (0.74 to 0.97). Chlorhexidine was associated with increased mortality (odds ratio 1.25, 1.05 to 1.50). When each intervention was compared with the other, both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine. The difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain. CONCLUSION Selective digestive decontamination has a favourable effect on mortality in adult patients in general intensive care units. In these patients, the effect of selective oropharyngeal decontamination is less certain. Both selective digestive decontamination and selective oropharyngeal decontamination are superior to chlorhexidine, and there is a possibility that chlorhexidine is associated with increased mortality.
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Affiliation(s)
- Richard Price
- Intensive Care Unit, Royal Alexandra Hospital, Paisley PA2 9PN, UK
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