Toothbrushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia

Impaired oral health: a required companion of bacterial aspiration pneumonia

Laryngotracheal aspiration has a widely-held reputation as a primary cause of lower respiratory infections, such as pneumonia, and is a major concern of care providers of the seriously ill orelderly frail patient. Laryngeal mechanical inefficiency resulting in aspiration into the lower respiratory tract, by itself, is not the cause of pneumonia. It is but one of several factors that must be present simultaneously for pneumonia to develop. Aspiration of oral and gastric contentsoccurs often in healthy people of all ages and without significant pulmonary consequences. Inthe seriously ill or elderly frail patient, higher concentrations of pathogens in the contents of theaspirate are the primary catalyst for pulmonary infection development if in an immunocompromised lower respiratory system. The oral cavity is a complex and ever changing eco-environment striving to maintain homogeneity among the numerous microbial communities inhabiting its surfaces. Poor maintenance of these surfaces to prevent infection can result inpathogenic changes to these microbial communities and, with subsequent proliferation, can altermicrobial communities in the tracheal and bronchial passages. Higher bacterial pathogen concentrations mixing with oral secretions, or with foods, when aspirated into an immunecompromised lower respiratory complex, may result in bacterial aspiration pneumonia development, or other respiratory or systemic diseases. A large volume of clinical evidence makes it clear that oral cleaning regimens, when used in caring for ill or frail patients in hospitals and long-term care facilities, drastically reduce the incidence of respiratory infection and death. The purpose of this narrative review is to examine oral health as a required causative companionin bacterial aspiration pneumonia development, and the effectiveness of oral infection control inthe prevention of this disease.

Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay

Could rebound explain the paradoxical lack of prevention effect against Staphylococcus aureus blood stream infections (BSIs) with antibiotic-based decontamination intervention (BDI) methods among studies of ICU patients within the literature? Two meta-regression models were applied, each versus the group mean length of stay (LOS). Firstly, the prevention effects against S. aureus BSI [and S. aureus VAP] among 136 studies of antibiotic-BDI versus other interventions were analyzed. Secondly, the S. aureus BSI [and S. aureus VAP] incidence in 268 control and intervention cohorts from studies of antibiotic-BDI versus that among 165 observational cohorts as a benchmark was modelled. In model one, the meta-regression line versus group mean LOS crossed the null, with the antibiotic-BDI prevention effect against S. aureus BSI at mean LOS day 7 (OR 0.45; 0.30 to 0.68) inverted at mean LOS day 20 (OR 1.7; 1.1 to 2.6). In model two, the meta-regression line versus group mean LOS crossed the benchmark line, and the predicted S. aureus BSI incidence for antibiotic-BDI groups was 0.47; 0.09-0.84 percentage points below versus 3.0; 0.12-5.9 above the benchmark in studies with 7 versus 20 days mean LOS, respectively. Rebound within the intervention groups attenuated and inverted the prevention effect of antibiotic-BDI against S. aureus VAP and BSI, respectively. This explains the paradoxical findings.

Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia: A Systematic Review and Meta-Analysis

Importance

Hospital-acquired pneumonia (HAP) is the most common and morbid health care-associated infection, but limited data on effective prevention strategies are available.

Objective

To determine whether daily toothbrushing is associated with lower rates of HAP and other patient-relevant outcomes.

Data Sources

A search of PubMed, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and 3 trial registries was performed from inception through March 9, 2023.

Study Selection

Randomized clinical trials of hospitalized adults comparing daily oral care with toothbrushing vs regimens without toothbrushing.

Data Extraction and Synthesis

Data extraction and risk of bias assessments were performed in duplicate. Meta-analysis was performed using random-effects models.

Main Outcomes and Measures

The primary outcome of this systematic review and meta-analysis was HAP. Secondary outcomes included hospital and intensive care unit (ICU) mortality, duration of mechanical ventilation, ICU and hospital lengths of stay, and use of antibiotics. Subgroups included patients who received invasive mechanical ventilation vs those who did not, toothbrushing twice daily vs more frequently, toothbrushing provided by dental professionals vs general nursing staff, electric vs manual toothbrushing, and studies at low vs high risk of bias.

Results

A total of 15 trials met inclusion criteria, including 10 742 patients (2033 in the ICU and 8709 in non-ICU departments; effective population size was 2786 after shrinking the population to account for 1 cluster randomized trial in non-ICU patients). Toothbrushing was associated with significantly lower risk for HAP (risk ratio [RR], 0.67 [95% CI, 0.56-0.81]) and ICU mortality (RR, 0.81 [95% CI, 0.69-0.95]). Reduction in pneumonia incidence was significant for patients receiving invasive mechanical ventilation (RR, 0.68 [95% CI, 0.57-0.82) but not for patients who were not receiving invasive mechanical ventilation (RR, 0.32 [95% CI, 0.05-2.02]). Toothbrushing for patients in the ICU was associated with fewer days of mechanical ventilation (mean difference, -1.24 [95% CI, -2.42 to -0.06] days) and a shorter ICU length of stay (mean difference, -1.78 [95% CI, -2.85 to -0.70] days). Brushing twice a day vs more frequent intervals was associated with similar effect estimates. Results were consistent in a sensitivity analysis restricted to 7 studies at low risk of bias (1367 patients). Non-ICU hospital length of stay and use of antibiotics were not associated with toothbrushing.

Conclusions

The findings of this systematic review and meta-analysis suggest that daily toothbrushing may be associated with significantly lower rates of HAP, particularly in patients receiving mechanical ventilation, lower rates of ICU mortality, shorter duration of mechanical ventilation, and shorter ICU length of stay. Policies and programs encouraging more widespread and consistent toothbrushing are warranted.

Does the presence of oral health teams influence the incidence of ventilator-associated pneumonia and mortality of patients in intensive care units? Systematic review

AIMS

To verify whether oral health teams influence the oral health status, ventilator-associated pneumonia incidence and mortality rate of patients in Intensive Care Units (ICU).

MATERIALS AND METHODS

Bibliographic searches were performed in PubMed, Scopus, Web of Science, Lilacs, Embase, Livivo, Open Grey, Academic Google, and Cochrane databases. The assessment of the methodological quality and risk of bias of the included studies and a random-effects meta-analysis to summarize relative risk data for ventilator-associated pneumonia (VAP) and mortality were performed. An analysis of the certainty of the evidence was performed for the main outcomes analyzed.

RESULTS

Records of 518 studies were analyzed by reading titles and abstracts. Five studies were included according to eligibility criteria. The meta-analysis showed that ICU patients undergoing dental care by an oral health team had a lower incidence of VAP (OR = 0.33; 95% CI: 014-0.76) but did not lower mortality rates (OR = 0.46 95% CI: 0.16-1.32). The certainty of the evidence was considered very low.

CONCLUSION

Dental care provided by oral health teams in a hospital environment did not influence oral health status or mortality, although it contributed to a reduction in VAP of patients admitted to the ICU.

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

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

Candida and the Gram-positive trio: testing the vibe in the ICU patient microbiome using structural equation modelling of literature derived data

Background

Whether Candida interacts with Gram-positive bacteria, such as Staphylococcus aureus, coagulase negative Staphylococci (CNS) and Enterococci, to enhance their invasive potential from the microbiome of ICU patients remains unclear. Several effective anti-septic, antibiotic, anti-fungal, and non-decontamination based interventions studied for prevention of ventilator associated pneumonia (VAP) and other ICU acquired infections among patients receiving prolonged mechanical ventilation (MV) are known to variably impact Candida colonization. The collective observations within control and intervention groups from numerous ICU infection prevention studies enables tests of these postulated microbial interactions in the clinical context.

Methods

Four candidate generalized structural equation models (GSEM), each with Staphylococcus aureus, CNS and Enterococci colonization, defined as latent variables, were confronted with blood culture and respiratory tract isolate data derived from 460 groups of ICU patients receiving prolonged MV from 283 infection prevention studies.

Results

Introducing interaction terms between Candida colonization and each of S aureus (coefficient + 0.40; 95% confidence interval + 0.24 to + 0.55), CNS (+ 0.68; + 0.34 to + 1.0) and Enterococcal (+ 0.56; + 0.33 to + 0.79) colonization (all as latent variables) improved the fit for each model. The magnitude and significance level of the interaction terms were similar to the positive associations between exposure to topical antibiotic prophylaxis (TAP) on Enterococcal (+ 0.51; + 0.12 to + 0.89) and Candida colonization (+ 0.98; + 0.35 to + 1.61) versus the negative association of TAP with S aureus (− 0.45; − 0.70 to − 0.20) colonization and the negative association of anti-fungal exposure and Candida colonization (− 1.41; − 1.6 to − 0.72).

Conclusions

GSEM modelling of published ICU infection prevention data enables the postulated interactions between Candida and Gram-positive bacteria to be tested using clinically derived data. The optimal model implies interactions occurring in the human microbiome facilitating bacterial invasion and infection. This interaction might also account for the paradoxically high bacteremia incidences among studies of TAP in ICU patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12982-022-00116-9.

GSEM modelling of published ICU infection prevention data from > 250 studies enables a test of and provides support to the interaction between Candida and Gram-positive bacteria.

The various ICU infection prevention interventions may each broadly impact the patient microbiome.

Nosocomial Pneumonia in the Mechanically Ventilated Patient

Ventilator-associated pneumonia (VAP) is a common complication occurring in critically ill patients who are mechanically ventilated and is the leading cause of nosocomial infection-related death. Etiologic agents for VAP widely differ based on the population of intensive care unit patients, duration of hospital stay, and prior antimicrobial therapy. VAP due to multidrug-resistant pathogens is associated with the highest morbidity and mortality, likely due to delays in appropriate antimicrobial treatment. International guidelines are currently available to guide diagnostic and therapeutic strategies. VAP can be prevented through various pharmacological and non-pharmacological interventions, which are more effective when grouped as bundles. When VAP is clinically suspected, diagnostic strategies should include early collection of respiratory samples to guide antimicrobial therapy. Empirical treatment should be based on the most likely etiologic microorganisms and antibiotics likely to be active against these microorganisms. Response to therapy should be reassessed after 3 to 5 days and antimicrobials adjusted or de-escalated to reduce the burden of the disease. Finally, considering that drug resistance is increasing worldwide, several novel antibiotics are being tested to efficiently treat VAP in the coming decades.

Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention

The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events in 2013 to increase the objectivity and reproducibility of surveillance and to encourage quality improvement programs to focus on preventing a broader array of complications. Ventilator-associated events are associated with a doubling of the risk of dying. Prospective studies have found that minimizing sedation, increasing spontaneous awakening and breathing trials, and conservative fluid management can decrease event rates and the duration of ventilation. Multifaceted interventions to enhance these practices can decrease ventilator-associated event rates.

Use of toothbrushing in conjunction with chlorhexidine for preventing ventilator-associated pneumonia: A random-effect meta-analysis of randomized controlled trials

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.

Asymmetric Effects of Decontamination Using Topical Antibiotics for the ICU Patient

There are several antiseptic, antibiotic and non-decontamination-based interventions for preventing intensive care unit (ICU) acquired infection. These have been evaluated in >200 studies. Infection prevention using topical antibiotic prophylaxis (TAP) appears to be the most effective. Whether antibiotic use in the ICU may influence the risk of infection among concurrent control patients within the same ICU and result in asymmetrical herd effects cannot be resolved with individual studies examined in isolation. The collective observations within control and intervention groups from numerous ICU infection prevention studies simulates a multi-center natural experiment enabling the herd effects of antibiotics to be evaluated. Among the TAP control groups, the incidences for both ventilator associated pneumonia (VAP) and mortality are unusually high in comparison to literature-derived benchmarks. Paradoxically, amongst the TAP intervention groups, the incidences of mortality are also unusually high and the VAP incidences are similar (i.e., not lower) compared to the incidences among studies of other interventions. By contrast, the mortality incidences among the intervention groups of other studies are similar to those among the intervention groups of TAP studies. Using topical antibiotics to prevent infections acquired within the ICU environment may result in profoundly asymmetrical effects.

Oral Candidiasis and COVID-19 in Users of Removable Dentures: Is Special Oral Care Needed?

Elderly patients with systemic disorders and immunocompromised patients seem to have a higher risk of developing morbidity from COVID-19. Candida albicans (C. albicans) is a potentially dangerous pathogen for these patients, especially for denture wearers with prosthetic stomatitis who require mechanical ventilation. C. albicans infection, the main candidiasis infection associated with denture wear, can complicate COVID-19 and increase the associated morbidity and mortality. Therefore, early diagnosis of C. albicans infection in COVID-19 patients is important to establish more effective antifungal treatment methods and prophylaxis strategies. Hospitalized COVID-19 patients should undergo an oral examination to assess their oral health, and those with poor oral health should receive the appropriate care and monitoring.

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia

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.

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

BACKGROUND

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

AIM

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Candida-Acinetobacter-Pseudomonas Interaction Modelled within 286 ICU Infection Prevention Studies

BACKGROUND

Whether Candida interacts to enhance the invasive potential of Acinetobacter and Pseudomonas bacteria cannot be resolved within individual studies. There are several anti-septic, antibiotic, anti-fungal, and non-decontamination-based interventions to prevent ICU acquired infection. These effective prevention interventions would be expected to variably impact Candida colonization. The collective observations within control and intervention groups from numerous ICU infection prevention studies simulates a multi-centre natural experiment with which to evaluate Candida, Acinetobacter and Pseudomonas interaction (CAPI).

METHODS

Eight Candidate-generalized structural equation models (GSEM), with Candida, Pseudomonas and Acinetobacter colonization as latent variables, were confronted with blood culture and respiratory tract isolate data derived from >400 groups derived from 286 infection prevention studies.

RESULTS

Introducing an interaction term between Candida colonization and each of Pseudomonas and Acinetobacter colonization improved model fit in each case. The size of the coefficients (and 95% confidence intervals) for these interaction terms in the optimal Pseudomonas (+0.33; 0.22 to 0.45) and Acinetobacter models (+0.32; 0.01 to 0.5) were similar to each other and similar in magnitude, but contrary in direction, to the coefficient for exposure to topical antibiotic prophylaxis (TAP) on Pseudomonas colonization (-0.45; -0.71 to -0.2). The coefficient for exposure to topical antibiotic prophylaxis on Acinetobacter colonization was not significant.

CONCLUSIONS

GSEM modelling of published ICU infection prevention data supports the CAPI concept. The CAPI model could account for some paradoxically high Acinetobacter and Pseudomonas infection incidences, most apparent among the concurrent control groups of TAP studies.

Structural equation modeling the "control of gut overgrowth" in the prevention of ICU-acquired Gram-negative infection

BACKGROUND

Conceptually, the "control of gut overgrowth" (COGO) is key in mediating prevention against infection with Gram-negative bacilli by topical antibiotic prophylaxis, a common constituent of selective digestive decontamination (SDD) regimens. However, the relative importance of the other SDD components, enteral and protocolized parenteral antibiotic prophylaxis, versus other methods of infection prevention and versus other contextual exposures cannot be resolved within individual studies.

METHODS

Seven candidate generalized structural equation models founded on COGO concepts were confronted with Pseudomonas and Acinetobacter bacteremia as well as ventilator-associated pneumonia data derived from > 200 infection prevention studies. The following group-level exposures were included in the models: use and mode of antibiotic prophylaxis, anti-septic and non-decontamination methods of infection prevention; proportion receiving mechanical ventilation; trauma ICU; mean length of ICU stay; and concurrency versus non-concurrency of topical antibiotic prophylaxis study control groups.

RESULTS

In modeling Pseudomonas and Acinetobacter gut overgrowth as latent variables, anti-septic interventions had the strongest negative effect against Pseudomonas gut overgrowth but no intervention was significantly negative against Acinetobacter gut overgrowth. Strikingly, protocolized parenteral antibiotic prophylaxis and concurrency each have positive effects in the model, enteral antibiotic prophylaxis is neutral, and Acinetobacter bacteremia incidences are high within topical antibiotic prophylaxis studies, moreso with protocolized parenteral antibiotic prophylaxis exposure. Paradoxically, topical antibiotic prophylaxis (moreso with protocolized parenteral antibiotic prophylaxis) appears to provide the strongest summary prevention effects against overall bacteremia and overall VAP.

CONCLUSIONS

Structural equation modeling of published Gram-negative bacillus infection data enables a test of the COGO concept. Paradoxically, Acinetobacter and Pseudomonas bacteremia incidences are unusually high among studies of topical antibiotic prophylaxis.

Efficacy of toothbrushing procedures performed in intensive care units in reducing the risk of ventilator-associated pneumonia: A systematic review

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.

Effects of different oral care scrubs on ventilator-associated pneumonia prevention for machinery ventilates patient: A protocol for systematic review, evidence mapping, and network meta-analysis

BACKGROUND

Ventilator-associated pneumonia (VAP) is defined as pneumonia develops in intensive care unit (ICU) patients who have been mechanically ventilated for at least 48 hours. Implementing effective oral car could reduce the incidence of VAP. However, previous studies on scrubs in oral care have failed to suggest which the best choice. Therefore, this protocol proposes to perform a network meta-analysis to evaluate the effectiveness of different oral care scrubs in preventing VAP.

METHODS

We are going to search the electronic databases: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, EMBASE, CINAHL, and Chinese Biomedical Literature Database. Study selection and data collection will be performed independently by 2 reviewers. Cochrane Risk of Bias tool will be used to assess the risk of bias of included studies. Odds ratio (OR) and 95% confidence intervals (CIs) will be used to assess the incidence rate of VAP in critical patients. The evidence mapping (EM) method will be introduce as a tool intended to complement the conventional systematic review (SR) and is suitable for this issue, at the same time, R software will be used for representing the outcome of EM-SR. We shall assess the heterogeneity on the bias of the magnitude of heterogeneity variance parameter (I or Cochrane Q). We are also going to conduct subgroup analysis and sensitivity analysis if needed. The application of Stata and R software will be performed the calculations.

RESULTS

The results of this study will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This network meta-analysis will provide comprehensive evidence of different scrubs in oral care for preventing VAP.

PROSPERO REGISTRATION NUMBER

CRD42018117019.

Oropharyngeal antisepsis in the critical patient and in the patient subjected to mechanical ventilation

Lower respiratory tract infections in the intubated patient constitute a serious health problem due to their associated morbidity and mortality. Microaspiration of the buccopharyngeal secretions is the main physiopathological mechanism underlying the development of pneumonia and tracheobronchitis in intubated patients. All care bundles designed to prevent these infections include the use of antiseptics to reduce buccopharyngeal colonization. Chlorhexidine is the antiseptic most frequently assessed in clinical trials and meta-analyses that conclude that oral hygiene with chlorhexidine reduces the incidence of ventilator-associated pneumonia - maximum effectiveness being achieved when the product is administered at a concentration of 2%. However, 2meta-analyses have warned of a possible increase in mortality when chlorhexidine is used as an oral antiseptic. We therefore recommend its use but with extreme caution during application in order to avoid aspiration of the antiseptic. This article is part of a supplement entitled "Antisepsis in the critical patient", which is sponsored by Becton Dickinson.

Unusually High Incidences of Pseudomonas Bacteremias Within Topical Polymyxin-Based Decolonization Studies of Mechanically Ventilated Patients: Benchmarking the Literature

Background

Topical polymyxin (PM)–based regimens to decolonize patients receiving prolonged mechanical ventilation (MV) have been widely studied. However, paradoxical bacteremia incidences remain unexplained.

Methods

The literature was searched for studies of topical PM–based regimens used to decontaminate MV patients reporting incidences of overall and Pseudomonas bacteremia data. In addition, observational groups without any intervention and trials of various interventions other than topical PM (non-PM studies) served to provide external benchmarks and additional points of reference, respectively. The bacteremia incidences were extracted from the control and intervention (component) groups of these studies and compared with metaregression using generalized estimating equation methods.

Results

The summary odds ratio derived from studies of topical PM–based interventions against overall bacteremia was 0.60 (95% confidence interval [CI], 0.53–0.69). Benchmark incidences per 100 MV patients for overall (mean, 8.9%; 95% CI, 6.9% to 10.9%) and Pseudomonas (mean, 0.7%; 95% CI, 0.5% to 1.1%) bacteremia were derived from 16 observational studies. By contrast, among 17 studies of topical PM, the mean incidences among control groups for overall (mean, 15.3%; 95% CI, 11.5% to 20.3%) and Pseudomonas (mean, 1.6%; 95% CI, 0.9% to 3.1%) bacteremia were both higher, whereas these incidences in the intervention groups for both topical PM and non-PM studies were in each case more similar to the respective benchmarks. These paradoxical incidences cannot readily be explained in metaregression models.

Conclusions

Paradoxically, despite an apparent prevention effect of topical PM–based methods against bacteremia overall, the incidences of Pseudomonas bacteremia within the component groups of these studies are unusually high vs literature-derived benchmarks.

Impact of an education program on the performance of nurses in providing oral care for mechanically ventilated children

BACKGROUND

Mechanically ventilated children are prone to pneumonia due to immobilization and lack of laryngeal (cough) reflex and swallowing. Nurses are directly responsible for many clinical approaches used to prevent ventilator-associated pneumonia.

OBJECTIVE

The research objective is to determine the effectiveness of the nurse education program on the performance of nurses in providing oral care for mechanically ventilated children.

METHODS

This quasi-experimental pretest-posttest design was conducted on 100 nurses (50 in each of the control and intervention groups) in pediatric intensive care units (PICU) in Tehran, 2015. The research tools included a demographic form and three checklists for evaluation of performance according to the clinical practice guidelines for the oral health status of children in PICU. Before intervention, the performance of nurses in both groups was observed at three stages and three different shifts, using an observational checklist. After one month, their performance was observed again with the same checklist at three stages and three different shifts in the PICU. The training was done in four 40-50 minute sessions in a workshop with a 4-week follow-up. The Chi-square test, Fisher's exact test, paired t-test, independent t-test, and regression analysis comprised the tools used to analyze the data.

FINDINGS

The mean performance scores of nurses before the education program in the intervention and control groups were 42.8 (±18.5) and 48.7 (±15.7), respectively. These scores improved to 68.6 (±31.4) and 48.6 (±15.4) four weeks after the intervention (p < 0.001).

CONCLUSION

The performance of nurses in providing oral care for mechanically ventilated children improved after the intervention. It is recommended to implement this program for all nurses, regardless of their ward or specialty, based on the clinical practice guidelines. The periodic refreshing in-service training program should be provided to nurses in PICU in order to enhance their performance in providing oral care.

Incidences of Pseudomonas aeruginosa-Associated Ventilator-Associated Pneumonia within Studies of Respiratory Tract Applications of Polymyxin: Testing the Stoutenbeek Concurrency Postulates

Regimens containing topical polymyxin appear highly effective at preventing ventilator-associated pneumonia (VAP) overall and, more so, VAP caused by Gram-negative bacteria. However, Stoutenbeek's postulates that VAP incidences within studies of topical antibiotics depend on the context of whether the component (control and intervention) groups of each study were concurrent versus nonconcurrent remain untested. The literature was searched for concurrent control (CC) versus nonconcurrent control (NCC) designed studies of respiratory tract applications of topical polymyxin to mechanically ventilated (MV) patients that reported incidences of Pseudomonas-associated ventilator-associated pneumonia (PsVAP). Studies of various interventions other than topical polymyxin (nonpolymyxin studies) served to provide additional points of reference. The PsVAP incidences within the component groups of all studies were benchmarked against groups from observational studies. This was undertaken by meta-regression using generalized estimating equation methods. Dot plots, caterpillar plots, and funnel plots enable visual benchmarking. The PsVAP benchmark (and 95% confidence interval [CI]) derived from 102 observational groups is 4.6% (4.0 to 5.3%). In contrast, the mean PsVAP within NCC polymyxin intervention groups (1.6%; CI, 1.0 to 4.5%) is lower than that of all other component group categories. The mean PsVAP within CC polymyxin control groups (9.9%; CI, 7.6 to 12.8%) is higher than that of all other component group categories. The PsVAP incidences of control and intervention groups of studies of respiratory tract applications of polymyxin are dependent on whether the groups were within a concurrent versus nonconcurrent study. Stoutenbeek's concurrency postulates are validated.

Is it necessary to have a dentist within an intensive care unit team? Report of a randomised clinical trial

OBJECTIVE

To evaluate the effectiveness of dental treatment in improving oral health in critical patients.

METHODS

This randomised clinical trial was conducted in a general intensive care unit (ICU) at a tertiary care public facility from 1 January 2011 to 8 August 2013. Data from 254 adult patients staying in the ICU for 48 hours or more were analysed. The experimental group (n = 127) had access to dental treatment provided by a dentist four to five times a week, in addition to routine oral hygiene, whereas the control group (n = 127) had access only to routine oral hygiene, including topical application of chlorhexidine, provided by the ICU nursing staff. The baseline oral health status of the enrolled patients was poor and included edentulism, caries, gingivitis, periodontitis and residual roots. Dental treatment consisted of toothbrushing, tongue scraping, removal of calculus, scaling and root planing, caries restoration and tooth extraction.

RESULTS

The Oral Hygiene Index Simplified (OHI-S) and Gingival Index (GI) scores decreased in the experimental group but did not change significantly in the control group during the ICU stay. Dental treatment prevented most of the episodes of respiratory tract infections, as previously reported. No severe adverse events from the dental treatment were observed.

CONCLUSION

From an interprofessional perspective, our results support the idea of including dentists in the ICU team to improve oral health in critical patients and effectively prevent respiratory tract infections, in addition to the improvement achievable by applying chlorhexidine alone.

Paradoxical Acinetobacter-associated ventilator-associated pneumonia incidence rates within prevention studies using respiratory tract applications of topical polymyxin: benchmarking the evidence base

BACKGROUND

Regimens containing topical polymyxin appear to be more effective in preventing ventilator-associated pneumonia (VAP) than other methods.

AIM

To benchmark the incidence rates of Acinetobacter-associated VAP (AAVAP) within component (control and intervention) groups from concurrent controlled studies of polymyxin compared with studies of various VAP prevention methods other than polymyxin (non-polymyxin studies).

METHODS

An AAVAP benchmark was derived using data from 77 observational groups without any VAP prevention method under study. Data from 41 non-polymyxin studies provided additional points of reference. The benchmarking was undertaken by meta-regression using generalized estimating equation methods.

RESULTS

Within 20 studies of topical polymyxin, the mean AAVAP was 4.6% [95% confidence interval (CI) 3.0-6.9] and 3.7% (95% CI 2.0-5.3) for control and intervention groups, respectively. In contrast, the AAVAP benchmark was 1.5% (95% CI 1.2-2.0). In the AAVAP meta-regression model, group origin from a trauma intensive care unit (+0.55; +0.16 to +0.94, P = 0.006) or membership of a polymyxin control group (+0.64; +0.21 to +1.31, P = 0.023), but not membership of a polymyxin intervention group (+0.24; -0.37 to +0.84, P = 0.45), were significant positive correlates.

CONCLUSIONS

The mean incidence of AAVAP within the control groups of studies of topical polymyxin is more than double the benchmark, whereas the incidence rates within the groups of non-polymyxin studies and, paradoxically, polymyxin intervention groups are more similar to the benchmark. These incidence rates, which are paradoxical in the context of an apparent effect against VAP within controlled trials of topical polymyxin-based interventions, force a re-appraisal.

Evidence summary: the relationship between oral health and pulmonary disease

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.

Prevalence and predictors of difficulty accessing the mouths of intubated critically ill adults to deliver oral care: An observational study

BACKGROUND

Oral care of intubated patients is essential to the prevention of infection and patient discomfort. However, barriers to oral access and delivery of oral care have received little attention.

OBJECTIVE

To determine prevalence and predictors of oral access difficulty.

DESIGN

A prospective, observational, multi-center study.

SETTINGS

Four intensive care units in Toronto, Canada.

PARTICIPANTS

Adult patients orally intubated for ≥48 h.

METHODS

We screened consecutive admissions once a week to identify eligible participants. We observed each patient and asked the patient's nurse about presence or absence of difficulty accessing the mouth to deliver oral care across three categories: (1) visualizing inside the mouth; (2) obtaining patient cooperation, or (3) inserting instruments for delivery of oral care. We asked nurses to identify presence of patient behaviors contributing to oral access difficulty and perceived level of difficulty on a Likert response scale. We examined patient and treatment characteristics associated with extreme difficulty (i.e., difficulty in all 3 categories) using a generalized estimating equation regression model.

RESULTS

A total of 428 patients were observed, 58% admitted with a medical diagnosis. More than half (57%) had ≥2 oral devices up to maximum of 4. Oral care difficulty was identified in 83% of patients and rated as moderate to high for 217 (51%). Difficulty concerned visibility (74%), patient cooperation (55%), and space to insert instruments (53%). Patient behaviors contributing difficulty included coughing/gagging (60%), mouth closing (49%), biting (45%) and localizing (27%) during care. Variables associated with extreme difficulty included neurological (OR 1.92, 95% CI 1.42-2.60) or trauma admission (OR 1.83, 95% CI 1.16-2.89), lack of pain assessment or treatment in the 4 h prior to oral care (OR 1.43, 95% CI 1.14-1.80), more oral devices (OR 1.40, 95% CI 1.05-1.87), and duration of intubation (OR 1.05, 95% CI 1.01-1.10). Absence of documented agitation in the 4 h prior to oral care was associated with less difficulty (OR 0.68, 95% CI 0.54-0.86).

CONCLUSIONS

Oral care is complex and difficulties are experienced in a vast majority of intubated patients. Some difficulties are amenable to correction such as pain management.

Ventilator-Associated Events and Their Prevention

The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events (VAEs) in 2013. The shift was designed to increase the objectivity and reproducibility of surveillance and to encourage quality-improvement programs to tackle a broader array of complications in mechanically ventilated patients. Prospective intervention studies have found that minimizing sedation, increasing the use of spontaneous awakening and breathing trials, and conservative fluid management can lower VAE rates and decrease duration of mechanical ventilation. Additional strategies to prevent VAEs include early mobility programs, low tidal volume ventilation, and restrictive transfusion thresholds.

Oral Care Effect on Intubated Patient with 0.2 per cent Chlorhexidine Gluconate and Tooth Brushing in Intensive Care Unit

Aims and Objectives:

Ventilator-associated pneumonia is associated with increased morbidity and mortality. The aim of this pilot study was to determine the effectiveness of oral care with both tooth brushing and 0.2 per cent chlor-hexidine gluconate compared to 0.2 per cent chlorhexidine gluconate alone for the intubated patient in an intensive care unit (ICU).

Materials and Methods:

Patient screening was done over a period of two months. After taking informed consent, those ICU patients were divided into two groups. Only nine subjects were enrolled. During the study, the experimental group (N = 4) got oral care that consisted of both tooth brushing and 0.2 per cent chlorhexidine gluconate thrice a day. The control group got oral care with 0.2 per cent chlorhexidine gluconate alone thrice a day. The data were analysed by IBM statistical software SPPS, version 24.

Results:

Preliminary results suggest that the risk of ventilator-associated pneumonia in intubated patients can be reduced by maintaining thrice-daily oral care involving both tooth brushing and 0.2 per cent chlorhexidine gluconate.

Conclusion:

Thrice-daily oral care consisted of both tooth brushing and 0.2 per cent chlorhexidine gluconate might be a promise as a ventilator-associated pneumonia-reduction strategy in ICU. Furthermore, more studies are required for its application widely.

Comparative study of 2 oral care protocols in intensive care units

BACKGROUND

The quality of oral care is important in limiting the emergence of ventilator-associated pneumonia (VAP) in intubated patients. Our main objective was to measure the quality improvement in oral care following the implementation of a new oral care protocol. We also monitored VAP rates.

MATERIAL/METHODS

This was a cohort study of patients in 5 adult ICUs covering different specialties. During period 1, caregivers used a foam stick for oral care and during period 2 a stick and tooth brushing with aspiration. Oral chlorhexidine was used during both periods. The caregivers rated improvement in oral health on the basis of 4 criteria (tongue, mucous membranes, gingivae, and teeth). Caregiver satisfaction was also assessed. The incidence of VAP was monitored.

RESULTS

A total of 2,030 intubated patients admitted to intensive care units benefited from oral care. The patient populations during the 2 periods were similar with regard to demographic data and VAP potential risk factors. Oral health was significantly better from the third day of oral care in period 2 onward (period 1, 6.4 ± 2.1; period 2, 5.6 ± 1.8; P = .043). Caregivers found the period 2 protocol easier to implement and more effective. VAP rates decreased significantly between the 2 periods (period 1, 12.8%; period 2, 8.5%; P = .002).

CONCLUSIONS

Our study showed that the implementation of a simple strategy improved the quality of oral care of patients in intensive care units, and decreased VAP rates.

Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: a randomized study

BACKGROUND

Nosocomial pneumonia has correlated to dental plaque and to oropharynx colonization in patients receiving mechanical ventilation. The interruption of this process, by preventing colonization of pathogenic bacteria, represents a potential procedure for the prevention of ventilator-associated pneumonia (VAP).

METHODS

The study design was a prospective, randomized trial to verify if oral hygiene through toothbrushing plus chlorhexidine in gel at 0.12% reduces the incidence of ventilatior-associated pneumonia, the duration of mechanical ventilation, the length of hospital stay and the mortality rate in ICUs, when compared to oral hygiene only with chlorhexidine, solution of 0.12%, without toothbrushing, in adult individuals under mechanical ventilation, hospitalized in Clinical/Surgical and Cardiology Intensive Care Units (ICU). The study protocol was approved by the Ethical Committee of Research of the Health Sciences Center of the Federal University of Pernambuco - Certificate of Ethical Committee Approval (CAAE) 04300012500005208. Because it was a randomized trial, the research used CONSORT 2010 checklist criteria.

RESULTS

Seven hundred sixteen patients were admitted into the ICU; 219 fulfilled the criteria for inclusion and 213 patients were included; 108 were randomized to control group and 105 to intervention group. Toothbrushing plus 0.12% chlorhexidine gel demonstrated a lower incidence of VAP throughout the follow up period, although the difference was not statistically significant (p = 0.084). There was a significant reduction of the mean time of mechanical ventilation in the toothbrushing group (p = 0.018). Regarding the length of hospital stay in the ICU and mortality rates, the difference was not statistically significant (p = 0.064).

CONCLUSIONS

The results obtained showed that, among patients undergoing toothbrushing there was a significant reduction in duration of mechanical ventilation, and a tendency to reduce the incidence of VAP and length of ICU stay, although without statistical significance.

TRIAL REGISTRATION

Retrospectively registered in the Brazilian Clinical Trials Registry (Registro Brasileiro de Ensaios Clínicos) - RBR-4TWH4M (4 September 2016).

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia

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.

Comparison of foam swabs and toothbrushes as oral hygiene interventions in mechanically ventilated patients: a randomised split mouth study

Introduction

During critical illness, dental plaque may serve as a reservoir of respiratory pathogens. This study compared the effectiveness of toothbrushing with a small-headed toothbrush or a foam-headed swab in mechanically ventilated patients.

Methods

This was a randomised, assessor-blinded, split-mouth trial, performed at a single critical care unit. Adult, orally intubated patients with >20 teeth, where >24 hours of mechanical ventilation was expected were included. Teeth were cleaned 12-hourly using a foam swab or toothbrush (each randomly assigned to one side of the mouth). Cleaning efficacy was based on plaque scores, gingival index and microbial plaque counts.

Results

High initial plaque (mean=2.1 (SD 0.45)) and gingival (mean=2.0 (SD 0.54)) scores were recorded for 21 patients. A significant reduction compared with initial plaque index occurred using both toothbrushes (mean change=−1.26, 95% CI −1.57 to −0.95; p<0.001) and foam swabs (mean change=−1.28, 95% CI −1.54 to −1.01; p<0.001). There was significant reduction in gingival index over time using toothbrushes (mean change=−0.92; 95% CI −1.19 to −0.64; p<0.001) and foam swabs (mean change=−0.85; 95% CI −1.10 to −0.61; p<0.001). Differences between cleaning methods were not statistically significant (p=0.12 for change in gingival index; p=0.24 for change in plaque index). There was no significant change in bacterial dental plaque counts between toothbrushing (mean change 3.7×10⁴ colony-forming units (CFUs); minimum to maximum (−2.5×10¹⁰ CFUs, 8.7×10⁷ CFUs)) and foam swabs (mean change 9×10⁴ CFUs; minimum to maximum (−3.1×10¹⁰ CFUs, 3.0×10⁷ CFUs)).

Conclusions

Patients admitted to adult intensive care had poor oral health, which improved after brushing with a toothbrush or foam swab. Both interventions were equally effective at removing plaque and reducing gingival inflammation.

Trial registration number

NCT01154257; Pre-results.

Respiratory pathogen colonization of dental plaque, the lower airways, and endotracheal tube biofilms during mechanical ventilation

PURPOSE

In mechanically ventilated patients, the endotracheal tube is an essential interface between the patient and ventilator, but inadvertently, it also facilitates the development of ventilator-associated pneumonia (VAP) by subverting pulmonary host defenses. A number of investigations suggest that bacteria colonizing the oral cavity may be important in the etiology of VAP. The present study evaluated microbial changes that occurred in dental plaque and lower airways of 107 critically ill mechanically ventilated patients.

MATERIALS AND METHODS

Dental plaque and lower airways fluid was collected during the course of mechanical ventilation, with additional samples of dental plaque obtained during the entirety of patients' hospital stay.

RESULTS

A "microbial shift" occurred in dental plaque, with colonization by potential VAP pathogens, namely, Staphylococcus aureus and Pseudomonas aeruginosa in 35 patients. Post-extubation analyses revealed that 70% and 55% of patients whose dental plaque included S aureus and P aeruginosa, respectively, reverted back to having a predominantly normal oral microbiota. Respiratory pathogens were also isolated from the lower airways and within the endotracheal tube biofilms.

CONCLUSIONS

To the best of our knowledge, this is the largest study to date exploring oral microbial changes during both mechanical ventilation and after recovery from critical illness. Based on these findings, it was apparent that during mechanical ventilation, dental plaque represents a source of potential VAP pathogens.

Healthcare-associated infections in the elderly: what's new

PURPOSE OF REVIEW

The high-risk population and current lack of knowledge regarding appropriate infection prevention in the long-term care (LTC) setting has contributed to substantial rates of resistance and healthcare-associated infections in this arena. More evidence-based research on LTC is necessary, particularly now that the elderly population is increasing.

RECENT FINDINGS

Proposed government mandates highlight the urgent need to combat antimicrobial resistance in the LTC setting. Recent studies focusing on unique strategies for the prevention of transmission and infection with multidrug-resistant organisms in nursing homes are discussed, as well as attempts to formulate clear antimicrobial stewardship programs.

SUMMARY

The long-term setting has unique challenges to instituting effective infection control precautions, therefore current accepted methods used in acute-care facilities need to be modified. Recent data suggest that prevention of transmission in LTC may be achieved with focus on high-risk patients or specific care-based activities rather than colonization status. Antimicrobial stewardship and consultation with specialized physicians may be important measures to combat resistance and adverse events in LTC. The prevention of unnecessary antibiotic use in palliative care may reduce rates of resistance as well as discomfort for terminal patients.

Oral hygiene regimes for mechanically ventilated patients that use chlorhexidine reduce ventilator-associated pneumonia

DATA SOURCES

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, LILACS, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Wan Fang Database, OpenGrey and ClinicalTrials.gov databases were searched. Reference lists of identified articles were also scanned for relevant papers. There were no language restrictions.

STUDY SELECTION

Randomised controlled trials (RCTs) evaluating OHC in the form of mouthwashes, swabs, toothbrushing or in combination in critically ill patients receiving mechanical ventilation were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction was carried out independently by two reviewers. Study authors were contracted for additional information. Random-effects meta-analyses were performed where data could be pooled.

RESULTS

Thirty-five RCTs (5374 participants) were included. Five trials (14%) were assessed at low risk of bias, 17 studies (49%) were at high risk of bias and 13 studies (37%) were assessed at unclear risk of bias in at least one domain. 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.Seventeen RCTs (2402 participants, two at high, 11 at unclear and four at low risk of bias) provide moderate quality evidence that CHX mouthrinse or gel, as part of OHC, compared to placebo or usual care is associated with a reduction in VAP (OR 0.60, 95% confidence intervals (CI) 0.47 to 0.77, P < 0.001, I(2) = 21%) A number needed to treat (NNT) of 15 (95% CI 10 to 34). There is no evidence of a difference between CHX and placebo/usual care in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There was insufficient evidence to determine whether there is a difference between CHX and placebo/usual care in the outcomes of duration of use of systemic antibiotics, oral health indices, microbiological cultures, caregivers' preferences or cost. Only three studies reported any adverse effects, and these were mild with similar frequency in CHX and control groups.Three trials in children found no evidence of a difference between OHC with CHX and placebo, and there was insufficient evidence to determine the effect of other outcomes. Four RCTs (828 participants, low quality evidence) compared to OHC without toothbrushing (± CHX), and for the outcome of VAP no evidence of a difference was found (OR 0.69, 95% CI 0.36 to 1.29, P = 0.24, I(2) = 64%). There was insufficient evidence to determine the effect of other outcomes.Only one trial 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.A range of other oral care solutions were compared. There is some weak evidence that povidone iodine mouthrinse is more effective than saline in reducing VAP (OR 0.35, 95% CI 0.19 to 0.65, P = 0.0009, I(2) = 53%) (two studies, 206 participants, high risk of bias). Due to the variation in comparisons and outcomes among the trials in this group there is insufficient evidence concerning the effects of other oral care solutions on the outcomes of this review.

CONCLUSIONS

Effective OHC is important for ventilated patients in intensive care. OHC that includes either chlorhexidine mouthwash or gel is associated with a 40% reduction in the odds of developing ventilator-associated pneumonia in critically ill adults. 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 CHX and toothbrushing is different from OHC with CHX alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP.

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update

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.

Antibacterial Action of a Condensed Tannin Extracted from Astringent Persimmon as a Component of Food Addictive Pancil PS-M on Oral Polymicrobial Biofilms

The purpose of this study was to evaluate the antibacterial activity against polymicrobial (PM) biofilms of a condensed tannin extracted from astringent persimmon (PS-M), which is contained in refreshing beverages commercially available in Japan. Salivary PM biofilms were formed anaerobically on glass coverslips for 24 and 72 h and were treated for 5 min with sterilized deionized water (DW), 0.05 and 0.2 wt% chlorhexidine digluconate (CHX), and 0.5-4.0 wt% PS-M solution. The colony forming units (CFU/mL) were determined and morphological changes of the biofilms were observed by scanning electron microscopy (SEM). The CFUs were lower in all PS-M and CHX groups compared to the DW group. PS-M exerted a dose-dependent effect. PS-M (1.53 × 10(7)) at a dose of 4.0 wt% had the same effect as 0.2 wt% CHX (2.03 × 10(7)), regardless of the culture period. SEM revealed the biofilm structures were considerably destroyed in the 4.0 wt% PS-M and 0.2 wt% CHX. These findings indicate that the antibacterial effects of PS-M, a naturally derived substance, are comparable to those of CHX. PS-M may keep the oral cavity clean and prevent dental caries and periodontal disease related to dental plaque, as well as systemic disease such as aspiration pneumonitis.

Microbial profiling of dental plaque from mechanically ventilated patients

Micro-organisms isolated from the oral cavity may translocate to the lower airways during mechanical ventilation (MV) leading to ventilator-associated pneumonia (VAP). Changes within the dental plaque microbiome during MV have been documented previously, primarily using culture-based techniques. The aim of this study was to use community profiling by high throughput sequencing to comprehensively analyse suggested microbial changes within dental plaque during MV. Bacterial 16S rDNA gene sequences were obtained from 38 samples of dental plaque sampled from 13 mechanically ventilated patients and sequenced using the Illumina platform. Sequences were processed using Mothur, applying a 97 % gene similarity cut-off for bacterial species level identifications. A significant ‘microbial shift’ occurred in the microbial community of dental plaque during MV for nine out of 13 patients. Following extubation, or removal of the endotracheal tube that facilitates ventilation, sampling revealed a decrease in the relative abundance of potential respiratory pathogens and a compositional change towards a more predominantly (in terms of abundance) oral microbiota including Prevotella spp., and streptococci. The results highlight the need to better understand microbial shifts in the oral microbiome in the development of strategies to reduce VAP, and may have implications for the development of other forms of pneumonia such as community-acquired infection.

Hospitalisation impacts on oral hygiene: an audit of oral hygiene in a metropolitan health service

BACKGROUND

Poor oral health has been associated with systemic diseases, morbidity and mortality. Many patients in hospital environments are physically compromised and rely upon awareness and assistance from health professionals for the maintenance or improvement of their oral health. This study aimed to identify whether common individual and environment factors associated with hospitalisation impacted on oral hygiene.

METHODS

Data were collected during point prevalence audits of patients in the acute and rehabilitation environments on three separate occasions. Data included demographic information, plaque score, presence of dental hygiene products, independence level and whether nurse assistance was documented in the health record.

RESULTS

Data were collected for 199 patients. A higher plaque score was associated with not having a toothbrush (p = 0.002), being male (p = 0.007), being acutely unwell (p = 0.025) and requiring nursing assistance for oral hygiene (p = 0.002). There was fair agreement between the documentation of requiring assistance for oral care and the patient independently able to perform oral hygiene (ICC = 0.22).

CONCLUSION

Oral hygiene was impacted by factors arising from hospitalisation, for those without a toothbrush and male patients of acute wards. Establishment of practices that increase awareness and promote good oral health should be prioritised.

Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update

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.

A cluster-randomized controlled trial of a multicomponent intervention protocol for pneumonia prevention among nursing home elders

BACKGROUND

Pneumonia remains an important public health problem among elderly nursing home residents. This clinical trial sought to determine if a multicomponent intervention protocol, including manual tooth/gum brushing plus 0.12% chlorhexidine oral rinse, twice per day, plus upright positioning during feeding, could reduce the incidence of radiographically documented pneumonia among nursing home residents, compared with usual care.

METHODS

This cluster-randomized clinical trial was conducted in 36 nursing homes in Connecticut. Eligible residents >65 years with at least 1 of 2 modifiable risk factors for pneumonia (ie, impaired oral hygiene, swallowing difficulty) were enrolled. Nursing homes were randomized to the multicomponent intervention protocol or usual care. Participants were followed for up to 2.5 years for development of the primary outcome, a radiographically documented pneumonia, and secondary outcome, a lower respiratory tract infection (LRTI) without radiographic documentation.

RESULTS

A total of 834 participants were enrolled: 434 to intervention and 400 to usual care. The trial was terminated for futility. The number of participants in the intervention vs control arms with first pneumonia was 119 (27.4%) vs 94 (23.5%), respectively, and with first LRTI, 125 (28.8%) vs 100 (25.0%), respectively. In a multivariable Cox regression model, the hazard ratio in the intervention vs control arms, respectively, was 1.12 (95% confidence interval [CI], .84-1.50; P = .44) for first pneumonia and 1.07 (95% CI, .79-1.46, P = .65) for first LRTI.

CONCLUSIONS

The multicomponent intervention protocol did not significantly reduce the incidence of first radiographically confirmed pneumonia or LRTI compared with usual care in nursing home residents.

CLINICAL TRIALS REGISTRATION

NCT00975780.

Effectiveness of a Dental Care Intervention in the Prevention of Lower Respiratory Tract Nosocomial Infections among Intensive Care Patients: A Randomized Clinical Trial

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&lt; .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

Ventilator-associated pneumonia prevention methods using topical antibiotics: herd protection or herd peril?

Ventilator-associated pneumonia (VAP) develops in approximately 20% of patients in the ICU receiving prolonged mechanical ventilation (MV). Among the range of methods for preventing VAP, the evidence base for topical antibiotics (TAs), including selective digestive decontamination, appears to be the most compelling. However, several observations are puzzling, and the contextual influence resulting from concurrent use of both topical placebo and TA within an ICU remains untested. As with herd protection conferred by vaccination, contextual influences resulting from a population-based intervention cannot be estimated at the level of a single trial. Estimating contextual effects requires multilevel random-effects methods. In this way the dispersion in VAP incidence across groups from 206 studies, as cited in various-source systematic reviews, was calibrated. The benchmark mean VAP incidence derived from 49 observational groups of patients receiving MV is 23.7% (95% CI, 20.6%-27.2%). In contrast, for 20 and 15 concurrent control groups from the TA evidence base that did vs did not receive topical placebo, respectively, this incidence is 38% (95% CI, 29%-48%) and 33% (95% CI, 20%-50%). This contextual influence remains significant in a meta-regression model adjusted for group-level variables, such as within a trauma ICU context. The mean VAP incidence for five other categories of control groups from the broader evidence base is within four percentage points of the benchmark. The contextual effect of TA is paradoxic, peculiar, potent, perfidious, and potentially perilous. The TA evidence base requires reappraisal to consider this herd peril.