Oral clearance and pathogenic oropharyngeal colonization in the elderly

Quantitative Evaluation of Periodontitis for Predicting the Occurrence of Postoperative Pneumonia After Oncologic Esophagectomy

BACKGROUND

Periodontitis is a biofilm-associated inflammatory periodontal disease associated with postoperative complications after esophagectomy. However, few studies have evaluated the inflammatory burden posed by periodontitis quantitively for patients undergoing oncologic esophagectomy. This study aimed to clarify the relationship between periodontitis and postoperative pneumonia using periodontal inflammatory surface area (PISA).

METHODS

The study analyzed 251 patients who underwent esophagectomy for esophageal cancer. The patients were classified into low-PISA and high-PISA groups according to preoperative PISA, and the relationship between the occurrence and severity of postoperative pneumonia was investigated.

RESULTS

The high-PISA group (n = 69) included more males (P < 0.001) and patients with poor performance status (P < 0.024). Postoperative pneumonia occurred more frequently in the high-PISA group than in the low-PISA group (31.9 % vs. 15.9 %; P = 0.008), whereas the incidences of other complications did not differ significantly. In addition, the incidence of severe pneumonia was significantly higher in the high-PISA group (7.2 % vs. 1.6 %; P = 0.038). In the multivariable analysis for adjustment of preoperative confounders, age older than 70 years (odds ratio [OR], 2.62; P = 0.006), high PISA (OR, 2.45; P = 0.012), and smoking history (OR, 2.78; P = 0.006) were the independent variables predicting postoperative pneumonia.

CONCLUSION

Preoperative higher PISA was significantly associated with the occurrence of overall and severe postoperative pneumonia. The quantitative evaluation of periodontitis using PISA is a useful measure for predicting postoperative pneumonia, and intensive periodontal intervention may contribute to decreasing postoperative pneumonia.

Prevention of microbial colonization of feeding tubes in the intensive care unit

BACKGROUND

Various microorganisms which increase the mortality rate in the intensive care unit (ICU) cause microbial colonization of the nasogastric tube (NGT) and use the NGT as a reservoir.

AIM

To detect the colonization on the NGT and to determine the effect that training regarding hand hygiene, NGT management, and enteral feeding (EF) provided to ICU nurses and auxiliary service staff (ASS) has on the level of NGT colonization.

STUDY DESIGN

A quasi-experimental pre-test and post-test control design was used in this study. Microbial samples were taken from the outer and inner parts of NGT. The microorganisms were categorized as: group 1, no risk; group 2, low risk pathogenic; group 3, high-risk pathogenic group. The training was given to nurses (n = 15) and ASS (n = 7). Hand hygiene, NGT, and EF care training are provided to nurses and ASS by researchers. A total of three training sessions were scheduled to be held in 3 weeks so that all health care staff members were trained. Each session lasted 2 h in total. Patients were assigned to a group if one of the microorganisms presented on the outer surface of the patient's feeding tube and/or on the hub. The hand hygiene compliance was evaluated by direct observation according to the World Health Organization hand hygiene indications.

RESULTS

The study was conducted with 46 patients. Evaluating the patients for the presence of microorganisms before education revealed that 4.3% were in group 1, 21.8% were in group 2, and 73.9% were in group 3. After the education, evaluating the samples for the presence of microorganisms revealed that 39.1% were in group 1, 13% were in group 2, and 47.8% were in group 3. A statistically significant difference was found between the number of samples included in the groups after the participants had received training (H = 8.186; p = .017).

CONCLUSIONS

An NGT could act as a reservoir of microbial colonization and high-risk microorganisms could be on the tube. Providing training not only to nurses but also to ASS will help reduce the risk of colonization.

RELEVANCE TO CLINICAL PRACTICE

Eliminating such colonization with effective hand hygiene during NGT feeding is a cost-effective method. Providing training not only to nurses but also to ASS will help obtain the optimum benefit from patient care.

Effect of 0.12% Chlorhexidine Oral Rinse on Preventing Hospital-Acquired Pneumonia in Nonventilator Inpatients

BACKGROUND

Nonventilator hospital-associated pneumonia (NV-HAP) is a nosocomial infection with a multifactorial etiology that is particularly prevalent in individuals with poor oral health.

PURPOSE

This study was designed to determine the effect of a 0.12% chlorhexidine gluconate oral rinse intervention on oral health and on reducing NV-HAP in inpatients.

METHODS

A randomized, double-blind, and triple-arm clinical trial was conducted on a sample of 103 patients aged ≥ 50 years. Using the blocking sample method, patients were randomly assigned into three groups. These included Group A, using an oral rinse solution of 0.12% chlorhexidine; Group B, using Listerine; and Group C, using a standard saline oral rinse. In addition to routine hospital-associated pneumonia preventative nursing care, the participants used the oral rinse solutions twice a day with a period of at least 9 hours between each use. Oral health, the degree of bacterial exposure, and the clinical pneumonia index scale were evaluated in each of the groups at baseline (first day), on Intervention Days 3 and 7, and at discharge. The clearance rate was calculated by dividing the number of bacteria cleared by the total frequency of oral bacteria in the collected culture × 100%.

RESULTS

Each arm of the study was composed of 34-35 participants, with an average hospitalization duration of 7.5 days. There was no incidence of NV-HAP or any changes in clinical pulmonary infection score among the three groups. Group A achieved a more significant improvement in oral health assessment tool scores between baseline and discharge than either Group B or C ( p = .03), particularly in the tongue, gums, and tissues; saliva; and oral cleanliness subscales. In addition, Group A reported higher clearance rates for Staphylococcus (100.00% vs. 66.67% vs. 66.67%, respectively), Escherichia coli (100.00% vs. 60.00% vs. 66.67%, respectively), and Pseudomonas aeruginosa (75.00% vs. 46.30% vs. 25.00%, respectively) than Groups B and C.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Although the results do not provide evidence supporting the use of a 0.12% chlorhexidine oral rinse as better in terms of preventing NV-HAP in middle-aged and elderly inpatients, nursing supervision was found to have an overall positive effect on oral health. The use of oral rinse with 0.12% chlorhexidine for nonventilated patients with poor oral health may be recommended.

Oral care measures for preventing nursing home-acquired pneumonia

BACKGROUND

Pneumonia in residents of nursing homes can be termed nursing home-acquired pneumonia (NHAP). NHAP is one of the most common infections identified in nursing home residents and has the highest mortality of any infection in this population. NHAP is associated with poor oral hygiene and may be caused by aspiration of oropharyngeal flora into the lung. Oral care measures to remove or disrupt oral plaque might reduce the risk of NHAP. This is the first update of a review published in 2018.

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

An information specialist searched CENTRAL, MEDLINE, Embase, one other database and three trials registers up to 12 May 2022. We also used additional search methods to identify published, unpublished and ongoing studies.

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 ratios (RRs) for dichotomous outcomes, mean differences (MDs) for continuous outcomes, and hazard ratios (HRs) or incidence rate ratio (IRR) for time-to-event outcomes, using random-effects models.

MAIN RESULTS

We included six RCTs (6244 participants), all of which were at high risk of bias. Three studies were carried out in Japan, two in the USA, and one in France. The studies evaluated one comparison: professional oral care versus usual oral care. We did not include the results from one study (834 participants) because it had been stopped at interim analysis.  Consistent results from five studies, with 5018 participants, provided insufficient evidence of a difference between professional oral care and usual (simple, self-administered) oral care in the incidence of pneumonia. Three studies reported HRs, one reported IRRs, and one reported RRs. Due to the variation in study design and follow-up duration, we decided not to pool the data. We downgraded the certainty of the evidence for this outcome by two levels to low: one level for study limitations (high risk of performance bias), and one level for imprecision. There was low-certainty evidence from meta-analysis of two individually randomised studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24 months' follow-up (RR 0.43, 95% CI 0.25 to 0.76, 454 participants). Another study (2513 participants) reported insufficient evidence of a difference for this outcome at 18 months' follow-up. Three studies measured all-cause mortality and identified insufficient evidence of a difference between professional and usual oral care at 12 to 30 months' follow-up. Only one study (834 participants) measured the 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-certainty evidence suggests that professional oral care may reduce mortality compared to usual care when measured at 24 months, the effect of professional oral care on preventing NHAP remains largely unclear. Low-certainty evidence was inconclusive about the effects of this intervention on incidence and number of first episodes of NHAP. Due to differences in study design, effect measures, follow-up duration, and composition of the interventions, we cannot determine the optimal oral care protocol from current evidence.  Future trials will require larger samples, robust methods that ensure low risk of bias, and more practicable interventions for nursing home residents.

Pneumonia, Aspiration Pneumonia, or Frailty-Associated Pneumonia?

Pneumonia is a common reason for admission afflicting frail older adults. Those who are the frailest are more likely to be provided with a diagnosis of aspiration pneumonia. This diagnosis has no clear definition and no clinical consensus. It is therefore time to stop attempting to differentiate between pneumonia type and use the term frailty-associated pneumonia.

Modeling insights into SARS-CoV-2 respiratory tract infections prior to immune protection

Mechanistic insights into human respiratory tract (RT) infections from SARS-CoV-2 can inform public awareness as well as guide medical prevention and treatment for COVID-19 disease. Yet the complexity of the RT and the inability to access diverse regions pose fundamental roadblocks to evaluation of potential mechanisms for the onset and progression of infection (and transmission). We present a model that incorporates detailed RT anatomy and physiology, including airway geometry, physical dimensions, thicknesses of airway surface liquids (ASLs), and mucus layer transport by cilia. The model further incorporates SARS-CoV-2 diffusivity in ASLs and best-known data for epithelial cell infection probabilities, and, once infected, duration of eclipse and replication phases, and replication rate of infectious virions. We apply this baseline model in the absence of immune protection to explore immediate, short-term outcomes from novel SARS-CoV-2 depositions onto the air-ASL interface. For each RT location, we compute probability to clear versus infect; per infected cell, we compute dynamics of viral load and cell infection. Results reveal that nasal infections are highly likely within 1-2 days from minimal exposure, and alveolar pneumonia occurs only if infectious virions are deposited directly into alveolar ducts and sacs, not via retrograde propagation to the deep lung. Furthermore, to infect just 1% of the 140 m2 of alveolar surface area within 1 week, either 103 boluses each with 106 infectious virions or 106 aerosols with one infectious virion, all physically separated, must be directly deposited. These results strongly suggest that COVID-19 disease occurs in stages: a nasal/upper RT infection, followed by self-transmission of infection to the deep lung. Two mechanisms of self-transmission are persistent aspiration of infected nasal boluses that drain to the deep lung and repeated rupture of nasal aerosols from infected mucosal membranes by speaking, singing, or cheering that are partially inhaled, exhaled, and re-inhaled, to the deep lung.

Evaluation of Oropharyngeal Dysphagia in Older Patients for Risk Stratification of Pneumonia

Objective

Nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) are widely used techniques to feed older patients with oropharyngeal dysphagia. Aspiration pneumonia is the most common cause of death in these patients. This study aimed to evaluate the role of oropharyngeal dysphagia in older patients on long-term enteral feeding for risk stratification of pneumonia requiring hospitalization.

Methods

We performed modified flexible endoscopic evaluation of swallowing to evaluate oropharyngeal dysphagia in older patients and conducted prospective follow-up for pneumonia requiring hospitalization. A total of 664 oral-feeding patients and 155 tube-feeding patients were enrolled. Multivariate Cox analysis was performed to identify risk factors of pneumonia requiring hospitalization.

Results

Multivariate analyses showed that the risk of pneumonia requiring hospitalization significantly increased in older patients and in patients with neurological disorders, tube feeding, and oropharyngeal dysphagia. Subgroup analysis revealed that the risk of pneumonia requiring hospitalization was significantly lower in patients with PEG than in those with NGT among the patients with oropharyngeal dysphagia (adjusted hazard ratio 0.26, 95% confidence interval: 0.11–0.63, P = 0.003).

Conclusions

For older patients with oropharyngeal dysphagia requiring long-term enteral tube feeding, PEG is a better choice than NGT. Further research is needed to elucidate the role of oropharyngeal dysphagia in enteral feeding in older patients.

The Relationships Among Periodontitis, Pneumonia and COVID-19

Periodontitis is a chronic inflammatory disease of the supporting structures of the teeth that affects approximately half of adults 30 years and older. There is increasing interest in the direct and indirect relationships between periodontitis and systemic diseases, including respiratory diseases. The aim of this study was to assess the evidence on links among periodontitis, pneumonia, and COVID-19. Oral and periodontal bacteria may be linked to respiratory disease directly by aspiration of pathogens into the lungs causing pneumonia. As SARS-CoV-2 began to spread worldwide in 2020, questions have arisen of how periodontal disease may also be connected to SARS-CoV-2 infection and severity, including potential replication and dissemination of the virus from periodontal pockets. Some proposed mechanisms include the oral cavity acting as a reservoir or point of entry for SARS-CoV-2, overgrowth of periodontal pathogens, and increased production of proinflammatory cytokines. Due to potential links between periodontal disease and respiratory infections like pneumonia and SARS-CoV-2, oral hygiene and management of periodontitis remain essential to help reduce infection and transmission of SARS-CoV-2.

Pathogenic oral bacteria in hospitalised patients with dysphagia: The silent epidemic

Background

Aspiration pneumonia is a serious and fatal complication of dysphagia, secondary to the ingestion of bacteria-laden secretions. However, no studies have documented the oral hygiene features present in patients who present with dysphagia.

Objectives

The purpose of this study was to describe the oral hygiene problems of adults admitted to a sub-acute rehabilitation hospital and who presented with dysphagia.

Methods

A descriptive, cross-sectional survey was conducted, during which 40 participants – 57.5% (n = 23) male and 42.5% (n = 17) female – underwent a clinical swallow evaluation using the Mann Assessment of Swallowing Ability (MASA) augmented with cervical auscultation (CA) and pulse oximetry (PO), an oral hygiene assessment using an adapted version of the Oral Health Assessment Tool (OHAT), followed by microbiology laboratory analysis of buccal swab samples to detect bacteria not considered part of the normal oral flora.

Results

Results indicated that poor oral hygiene status was a common feature amongst all participants who presented with dysphagia. The most prevalent oral hygiene issues were related to abnormalities concerning saliva (60%), oral cleanliness (82.5%), the tongue (80%) and the use of dentures (71.4%). A high prevalence, 62.5% (n = 25), of opportunistic bacteria was found. The most commonly occurring bacteria groups were: (1) Candida albicans (47.5%) and (2) respiratory pathogens (37.5%) such as Klebsiella pneumoniae and Staphylococcus aureus.

Conclusion

Persons with dysphagia have poor oral hygiene which creates favourable environments for bacteria to flourish and increases the prevalence of pathogenic oral bacteria associated with the development of aspiration pneumonia. The management of oral health issues for persons with dysphagia should receive greater attention during hospitalisation.

Re-initiation of Oral Food Intake Following Enteral Nutrition Alters Oral and Gut Microbiota Communities

Stroke is associated with multiple forms of disability, including dysphagia. Post-stroke dysphagia increases the risks of pneumonia and mortality and often results in cessation of oral feeding. However, appropriate rehabilitation methods can eventually lead to resumption of oral food intake. This study tried to clarify that re-initiating oral food intake could modify the composition of oral/gut microbial communities in patients with dysphagia. From 78 patients with sub-acute stage of stroke, 11 complete tube feeding subjects without taking antibiotics were enrolled and received rehabilitation for re-initiation of oral food intake, and 8 subjects were brought back to complete oral feeding. Oral and gut microbiota community profiles were evaluated using 16S rRNA sequencing of the saliva and feces samples before and after re-initiation of oral food intake in patients recovering from enteral nutrition under the same nutrient condition. Standard nutrition in the hospital was 1,840 kcal, including protein = 75 g, fat = 45 g, and carbohydrates = 280 g both for tube and oral feeding subjects. Oral food intake increased oral and gut microbiome diversity and altered the composition of the microbiome. Oral and gut microbiome compositions were drastically different; however, the abundance of family Carnobacteriaceae and genus Granulicatella was increased in both the oral and gut microbiome after re-initiation of oral food intake. Although oral microbiota showed more significant changes than the gut microbiota, metagenome prediction revealed the presence of more differentially enriched pathways in the gut. In addition, simpler co-occurrence networks of oral and gut microbiomes, indicating improved dysbiosis of the microbiome, were observed during oral feeding as compared to that during tube feeding. Oral food intake affects oral and gut microbiomes in patients recovering from enteral nutrition. Rehabilitation for dysphagia can modify systemic health by increasing the diversity and altering the composition and co-occurrence network structure of oral and gut microbial communities.

Association Between Postextubation Dysphagia and Long-Term Mortality Among Critically Ill Older Adults

BACKGROUND

Dysphagia following extubation is common in intensive care unit (ICU) patients. Diagnosing postextubation dysphagia allows identification of patients who are at highest risk for aspiration and its associated adverse outcomes. Older adults are at an increased risk of postextubation dysphagia and its complications due to multiple comorbidities, a higher baseline risk of dysphagia, and increased risk of pneumonia.

OBJECTIVES

We aimed to investigate the association between postextubation dysphagia and 1-year mortality in older patients. Secondary outcomes included ICU and hospital lengths of stay, ICU readmission, and place of discharge.

METHODS

We performed a retrospective cohort study from January 1 to December 31, 2013. ICU patients, aged 65 years and older, who were successfully extubated and underwent a formal swallow evaluation by a speech and language pathologist (SLP) were included. Dysphagia was graded using a seven-point scale, and those with at least mild-moderate dysphagia were labeled as having clinically significant dysphagia.

RESULTS

Of 1075 patients who were screened, 359 were survivors, aged 65 years and older; and of these survivors, 111 had a swallow evaluation performed by an SLP after liberation from mechanical ventilation. Mean age was 73.8 years (SD = 7.0 years), and 41.4% had clinically significant dysphagia. In a multivariable regression model, there was no significant association between dysphagia and 1-year mortality. Furthermore, there was no statistically significant difference in ICU or hospital length of stay, ICU readmission, or place of discharge of those with clinically significant dysphagia compared to those without.

CONCLUSIONS

Among mechanically ventilated ICU patients, aged 65 years and older, who underwent a swallow evaluation following extubation, dysphagia was not associated with mortality, ICU and hospital lengths of stay, ICU readmission, and place of discharge. Given conflicting evidence in the literature, larger prospective studies are needed to clarify whether postextubation dysphagia is associated with worse outcomes in older patients admitted to the ICU. J Am Geriatr Soc 67:1895-1901, 2019.

Influence of Preoperative Oropharyngeal Microflora on the Occurrence of Postoperative Pneumonia and Survival in Patients Undergoing Esophagectomy for Esophageal Cancer

OBJECTIVE

The aim of this study was to clarify the correlation between oropharyngeal microflora and postoperative complications as well as long-term survival after esophagectomy.

BACKGROUND

Although the oral cavity is known to be a potential reservoir for pathogens, the influence of abnormal oropharyngeal microflora on the outcomes of patients undergoing esophagectomy remains unknown.

METHODS

This study included 675 patients who underwent esophagectomy between 2007 and 2014. Saliva samples from the oropharynx were collected 2 days before the operation. There were 442 patients with indigenous flora (Ind group) and 233 with allopatric flora. Among the patients with allopatric flora, 140 had antibiotic-sensitive microbes only (Allo-S group) while 93 had different types of antibiotic-resistant microbes (Allo-R group). We investigated the correlation between the types of oropharyngeal microflora and the incidence of postoperative complications as well as long-term outcomes.

RESULTS

Sixteen microbes could be cultivated from the saliva samples. The incidence of postoperative pneumonia in the Allo-S and Allo-R groups was significantly higher than in the Ind group (P < 0.001). In addition, acute respiratory distress syndrome was more often observed in the Allo-R group than in the other groups (P = 0.002). A significantly higher rate of antibiotic use and longer hospital stays were observed in the Allo-R group compared with the Ind group. Multivariate logistic regression analysis revealed that the presence of allopatric antibiotic-resistant microbes in the oropharynx was an independent risk factor for postoperative pneumonia (odds ratio, 3.93; 95% confidence interval, 2.41-6.42). The overall survival was significantly poorer in the Allo-R group than in the other groups.

CONCLUSIONS

Preoperative oropharyngeal culture is a simple and low-cost method that can predict both the occurrence of postoperative pneumonia and poor prognosis after esophagectomy.

Oral care measures for preventing nursing home-acquired pneumonia

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.

Oropharyngeal Microbiota in Frail Older Patients Unaffected by Time in Hospital

Respiratory tract infections are the commonest nosocomial infections, and occur predominantly in frailer, older patients with multiple comorbidities. The oropharyngeal microbiota is the major reservoir of infection. This study explored the relative contributions of time in hospital and patient demographics to the community structure of the oropharyngeal microbiota in older patients with lower limb fracture. We collected 167 throat swabs from 53 patients (mean age 83) over 14 days after hospitalization, and analyzed these using 16S rRNA gene sequencing. We calculated frailty/comorbidity indices, undertook dental examinations and collected data on respiratory tract infections. We analyzed microbial community composition using correspondence (CA) and canonical correspondence analysis. Ten patients were treated for respiratory tract infection. Microbial community structure was related to frailty, number of teeth and comorbidity on admission, with comorbidity exerting the largest effect. Time in hospital neither significantly changed alpha (t = −0.910, p = 0.365) nor beta diversity (CA1 t = 0.022, p = 0.982; CA2 t = −0.513, p = 0.609) of microbial communities in patient samples. Incidence of respiratory pathogens were not associated with time in hospital (t = −0.207, p = 0.837), nor with alpha diversity of the oral microbiota (t = −1.599, p = 0.113). Patient characteristics at admission, rather than time in hospital, influenced the community structure of the oral microbiota.

Impact of oral gut decontamination on Staphylococcus aureus colonisation in patients undergoing allogeneic haematopoietic stem cell transplantation

Recipients of allogeneic haematopoietic stem cell transplantation (allo-HSCT) are severely immunocompromised and are at increased risk of infection. In this prospective, observational, single-centre study including 110 allo-HSCT recipients, the rate of Staphylococcus aureus colonisation was reduced from 11.8% to 0% (P <0.001) following peritransplant oral gut decontamination. No invasive S. aureus infections were observed.

New horizons in hospital acquired pneumonia in older people

Approximately 1.5% of hospital patients develop hospital acquired pneumonia. Aspiration is the major risk factor for pneumonia and is associated with reduced ability to mechanically clear respiratory pathogens into the stomach. Currently non-invasive methods of diagnosing hospital acquired pneumonia are less robust than invasive methods, and lead to over-diagnosis. Accurate diagnosis is key to surveillance, prevention and treatment of HAP, and also to improving outcomes; newer imaging modalities such as phase contrast X-ray imaging and nanoparticle enhanced magnetic resonance imaging may help. Potential preventative strategies such as systematic swallowing assessment in non-stroke patients, and interventions such as improving oral hygiene need further, robust randomised controlled trials. Antibiotics are likely to continue to be the mainstay of treatment, and new antibiotics such as ceftobiprole are likely to have a role in treating hospital acquired pneumonia. Given the spread of antimicrobial resistance, alternative treatment strategies including bacteriophages, peptides and antibodies are under investigation. Reducing the incidence of hospital acquired pneumonia could decrease length of hospital stay, reduce inappropriate antibiotic use, and both improve functional outcomes and mortality in our increasingly aged population.

Nutritional Aspects of Dysphagia Management

This chapter describes the nutritional aspects of dysphagia management by starting with the definition of these two conditions (dysphagia and malnutrition) that share three main clinical characteristics: (a) their prevalence is very high, (b) they can lead to severe complications, and (c) they are frequently underrecognized and neglected conditions. From an anatomical standpoint, dysphagia can result from oropharyngeal and/or esophageal causes; from a pathophysiological perspective, dysphagia can be caused by organic or structural diseases (either benign or malignant) or diseases causing impaired physiology (mainly motility and/or perception disorders). This chapter gathers up-to-date information on the screening and diagnosis of oropharyngeal dysphagia, the consequences of dysphagia (aspiration pneumonia, malnutrition, and dehydration), and on the nutritional management of dysphagic patients. Concerning this last topic, this chapter reviews the rheological aspects of swallowing and dysphagia (including shear and elongational flows) and its influence on the characteristics of the enteral nutrition for dysphagia management (solid/semisolid foods and thickened liquids; ready-to-use oral nutritional supplements and thickening powders), with special focus on the real characteristics of the bolus after mixing with human saliva.

Reinstituting Oral Feeding in Tube-Fed Adult Patients With Dysphagia

Feeding tubes are valuable assets in the rehabilitation of adult patients with dysphagia. Feeding tubes may be placed in response to perceived risks of airway compromise or insufficient nutrient intake. However, not all patients require long-term enteral feeding. With intensive dysphagia therapy, many patients will experience resolving deficits or improvement in swallowing ability. These patients require an appropriate strategy to transition from tube to oral feeding. This article reviews some of the basic characteristics of dysphagia and identifies specific swallowing difficulties in 2 groups of patients who often benefit from temporary enteral feeding: stroke survivors and patients treated for head and neck cancer. Specific suggestions are offered for clinical strategies to reinstitute oral feeding in these groups of tube-fed patients.

Dysphagia in the elderly: focus on rehabilitation strategies

Prevalence of oropharyngeal dysphagia among the elderly is high, but underestimated and underdiagnosed. It may give raise to relevant complications impacting on morbidity, hospital length of stay and health care costs. Dysphagia evaluation and management is a multidisciplinary task; it includes a detailed history taking, clinical and instrumental exams, and identification of the risk of aspiration. Long-standing individual abilities and impairments determine the goals of an ad hoc rehabilitation program. Currently there are no standard algorithmic approaches for the management of dysphagia in the elderly. Education of health professionals on early diagnosis and improvement of therapeutic strategies are mainstays to allow maximal recovery potential in this population. This narrative review summarizes the current rehabilitation approaches for dysphagia in the elderly. The aim is to inform the treating health care professionals, whether caring physician, physical medicine doctor, speech/swallowing therapist or nurse, on the state-of-the-art and stimulate discussion in the scientific community.

Salivary Anionic Changes after Radiotherapy for Nasopharyngeal Carcinoma: A 1-Year Prospective Study

Objectives

To investigate the salivary anionic changes of patients with nasopharyngeal carcinoma (NPC) treated by radiotherapy.

Material and Methods

Thirty-eight patients with T1-4, N0-2, M0 NPC received conventional radiotherapy. Stimulated whole saliva was collected at baseline and 2, 6 and 12 months after radiotherapy. Salivary anions levels were measured using ion chromatography.

Results

A reduction in stimulated saliva flow and salivary pH was accompanied by sustained changes in anionic composition. At 2 months following radiotherapy, there was a significant increase in chloride, sulphate, lactate and formate levels while significant reductions in nitrate and thiocyanate levels were found. No further changes in these anion levels were observed at 6 and 12 months. No significant changes were found in phosphate, acetate, or propionate levels throughout the study period.

Conclusions

Conventional radiotherapy has a significant and prolonged impact on certain anionic species, likely contributing to increased cariogenic properties and reduced antimicrobial capacities of saliva in NPC patients post-radiotherapy.

Streptococcus pneumoniae Colonization Disrupts the Microbial Community within the Upper Respiratory Tract of Aging Mice

Nasopharyngeal colonization by the Gram-positive bacterium Streptococcus pneumonia is a prerequisite for pneumonia and invasive pneumococcal diseases. Colonization is asymptomatic, involving dynamic and complex interplay between commensals, the host immune system, and environmental factors. The elderly are at an increased risk of developing pneumonia, which might be due to changes in the respiratory microbiota that would impact bacterial colonization and persistence within this niche. We hypothesized that the composition of the upper respiratory tract (URT) microbiota changes with age and subsequently can contribute to sustained colonization and inefficient clearance of S. pneumoniae To test this, we used a mouse model of pneumococcal colonization to compare the composition of the URT microbiota in young, middle-aged, and old mice in the naive state and during the course of colonization using nasal pharyngeal washes. Sequencing of variable region 3 (V3) of the 16S rRNA gene was used to identify changes occurring with age and throughout the course of S. pneumonia colonization. We discovered that age affects the composition of the URT microbiota and that colonization with S. pneumoniae is more disruptive of preexisting communities in older mice. We have further shown that host-pathogen interactions followingS. pneumonia colonization can impact the populations of resident microbes, including Staphylococcus and Haemophilus. Together, our findings indicate alterations to the URT microbiota could be detrimental to the elderly, resulting in increased colonization of S. pneumonia and decreased efficiency in its clearance.

Oropharyngeal dysphagia: manifestations and diagnosis

Swallowing disorders (dysphagia) have been recognized by the WHO as a medical disability associated with increased morbidity, mortality and costs of care. With increasing survival rates and ageing of the population, swallowing disorders and their role in causing pulmonary and nutritional pathologies are becoming exceedingly important. Over the past two decades, the study of oropharyngeal dysphagia has been approached from various disciplines with considerable progress in understanding its pathophysiology. This Review describes the most frequent manifestations of oropharyngeal dysphagia and the clinical as well as instrumental techniques that are available to diagnose patients with dysphagia. However, the clinical value of these diagnostic tests and their sensitivity to predict outcomes is limited. Despite considerable clinical research efforts, conventional diagnostic methods for oropharyngeal dysphagia have limited proven accuracy in predicting aspiration and respiratory disease. We contend that incorporation of measurable objective assessments into clinical diagnosis is needed and might be key in developing novel therapeutic strategies.

High prevalence of colonization of oral cavity by respiratory pathogens in frail older patients with oropharyngeal dysphagia

BACKGROUND

Aspiration pneumonia (AP) is caused by dysfunctional swallowing resulting in aspiration of material colonized by respiratory pathogens. The aim of this study was to assess and compare the swallowing physiology, health status, oral health status, and oral/nasal microbiota in frail older patients (FOP) with oropharyngeal dysphagia (OD) and a control group.

METHODS

We studied 47 FOP (>70 year) with OD by videofluoroscopy (17 with acute pneumonia -APN-, 15 with prior pneumonia-PNP- and 15 without) and 14 older controls without OD (H). Oral/nasal colonization by five respiratory pathogens was evaluated by qPCR, whereas commensal microbiota composition was assessed by pyrosequencing.

KEY RESULTS

(i) Frail older patients with OD presented similar comorbidities, poor functionality, polymedication, and prevalent videofluoroscopic signs of impaired safety of swallow (33.3-61.5%). However, patients with OD-APN also presented malnutrition, delayed laryngeal vestibule closure (409.23 ± 115.6 ms; p < 0.05), and silent aspirations (15.6%). (ii) Oral health was poor in all groups, 90% presented periodontitis and 72%, caries. (iii) Total bacterial load was similar in all groups, but higher in the oropharynx (>10(8) CFU/mL) than in the nose (<10(6) CFU/mL) (p < 0.0001). Colonization by respiratory pathogens was very high: 93% in OD patients (p < 0.05 vs H); 93% in OD-PNP (p < 0.05 vs H); 88% in OD-APN (p = 0.07 vs H), and lower in controls (67%).

CONCLUSIONS & INFERENCES

Frail older patients with OD had impaired health status, poor oral health, high oral bacterial load, and prevalence of oral colonization by respiratory pathogens and VFS signs of impaired safety of swallow, and were therefore at risk for contracting AP.

A descriptive study of nasogastric tube feeding among geriatric inpatients in Malaysia: utilization, complications, and caregiver opinions

The strong emphasis on feeding in Asian cultures may influence decisions for nasogastric (NG) tube feeding in geriatric inpatients. We evaluated the utility, complications, and opinions of caregivers toward NG tube feeding in an acute geriatric ward in a teaching hospital in Kuala Lumpur. Consecutive patients aged 65 years and older receiving NG tube feeding were included. Sociodemographic, clinical, and laboratory indices were recorded. Opinion on NG tube feeding were evaluated through face-to-face interviews with caregivers, recruited through convenience sampling. Of 432 patients admitted, 96 (22%), age ± standard deviation = 80.8 ± 7.4 years, received NG tube feeding. The complication and mortality rates were 69% and 38%, respectively. Diabetes (odds ratio [95% confidence interval] = 3.34 [1.07, 10.44], aspiration pneumonia (8.15 [2.43, 27.24]), impaired consciousness (3.13 [1.05, 9.36]), and albumin ≤26 g/dl (4.43 [1.46, 13.44]) were independent predictors of mortality. Other relatives were more likely than spouses (23.5 [3.59, 154.2]) and caregivers with tertiary education more likely than those with no formal education ( 18 [1.23, 262.7]) to agree to NG feeding. Sixty-four percent of caregivers felt NG tube feeding was appropriate at the end of life, mostly due to the fear of starvation. NG tube feeding is widely used in our setting, despite high complication and mortality rates, with likely influences from cultural emphasis on feeding.

Dental and microbiological risk factors for hospital-acquired pneumonia in non-ventilated older patients

Hospital acquired pneumonia (HAP) is often fatal in older patients. The mouth is the main reservoir of infection and studies have suggested that oral hygiene interventions may prevent HAP. The aim of this study was to investigate associations between HAP and preceding a) heavy dental plaque and b) oral carriage of potential respiratory pathogens in older patients with lower limb fracture to determine the target for intervention studies.

Risk factors for aspiration in community-acquired pneumonia: analysis of a hospitalized UK cohort

BACKGROUND

There is a move toward finding clinically useful "phenotypes" in community-acquired pneumonia: groups of patients displaying distinct clinical characteristics, microbiology, and prognosis. Aspiration pneumonia is an intuitive clinical phenotype; however, to date there are no recognized diagnostic criteria, and data regarding outcomes in suspected aspiration are limited.

METHODS

An observational study of 1348 patients hospitalized with community-acquired pneumonia in the United Kingdom examined both short- and long-term outcomes for patients at risk of aspiration pneumonia. Patients were defined as "at risk" in the presence of chronic neurologic disorders, esophageal disorders and dysphagia, impaired conscious level, vomiting, or witnessed aspiration. The primary outcome was 30-day mortality. Secondary outcomes included 1-year mortality, readmissions, and recurrent pneumonia within 1 year.

RESULTS

Some 13.8% of the cohort were classified as "at risk of aspiration." These patients were older (median age, 74 years [interquartile range, 60-84] vs 66 years [interquartile range, 49-77]; P < .0001) and more likely to have comorbidities (chronic liver disease 11.3% vs 3.7%, P < .0001; congestive heart failure 28% vs 17.1%, P = .0004; and stroke 26.9% vs 9.5%, P < .0001). Patients at risk of aspiration pneumonia had a poorer short-term outcome (30-day mortality 17.2% vs 7.7%, P < .0001), but after adjusting for their greater severity of illness and comorbidities this difference was not significant (odds ratio 1.05; 95% confidence interval [CI], 0.63-1.76; P = .8). However, patients with aspiration risk factors were at greater risk of poor long-term outcomes with increased 1-year mortality (hazard ratio [HR], 1.73; 95% CI, 1.15-2.58), increased risk of rehospitalization (HR, 1.52; 95% CI, 1.21-1.91), and a strong association with recurrent admissions with pneumonia (HR, 3.13; 95% CI, 2.05-4.78) after multivariable adjustment.

CONCLUSIONS

Using risk factors to identify patients at risk of aspiration pneumonia identifies a distinct clinically useful phenotype of patients with greater severity of disease and poorer long-term outcomes.

Use of videofluoroscopic swallowing study in patients with aspiration pneumonia

OBJECTIVE

To investigate the clinical characteristics of dysphagic elderly Korean patients diagnosed with aspiration pneumonia as well as to examine the necessity of performing a videofluoroscopic swallowing study (VFSS) in order to confirm the presence of dysphagia in such patients.

METHOD

The medical records of dysphagic elderly Korean subjects diagnosed with aspiration pneumonia were retrospectively reviewed for demographic and clinical characteristics as well as for VFSS findings.

RESULTS

In total, medical records of 105 elderly patients (81 men and 24 women) were reviewed in this study. Of the 105 patients, 82.9% (n=87) were admitted via the emergency department, and 41.0% (n=43) were confined to a bed. Eighty percent (n=84) of the 105 patients were diagnosed with brain disorders, and 68.6% (n=72) involved more than one systemic disease, such as diabetes mellitus, cancers, chronic cardiopulmonary disorders, chronic renal disorders, and chronic liver disorders. Only 66.7% (n=70) of the 105 patients underwent VFSS, all of which showed abnormal findings during the oral or pharyngeal phase, or both.

CONCLUSION

In this study, among 105 dysphagic elderly patients with aspiration pneumonia, only 66.7% (n=70) underwent VFSS in order to confirm the presence of dysphagia. As observed in this study, the evaluation of dysphagia is essential in order to consider elderly patients with aspiration pneumonia, particularly in patients with poor functional status, brain disorders, or more than one systemic disease. A greater awareness of dysphagia in the elderly, as well as the diagnostic procedures thereof, particularly VFSS, is needed among medical professionals in Korea.

Comparison between the radionuclide salivagram and videofluoroscopic swallowing study methods for evaluating patients with aspiration pneumonia

OBJECTIVE

A videofluoroscopic swallowing study (VFSS) is generally used to assess dysphagia and aspiration, although false-negative results may be obtained. Saliva aspiration may cause false-negative VFSS findings in elderly people. A radionuclide salivagram can be useful in detecting saliva aspiration. We therefore compared these two methods for the evaluation of patients with aspiration pneumonia.

METHODS

We prospectively enrolled 50 patients with aspiration pneumonia into this study. All patients underwent VFSS, and were evaluated on the Penetration-Aspiration Scale. A salivagram was performed on the day after VFSS and each patient received 1 mL Tc-99 m DTPA sublingually. Both dynamic and delayed images were obtained.

RESULTS

Aspiration was observed in 34% of patients by salivagram and in 42% by VFSS. The frequency of tests that were positive for aspiration pneumonia using a combination of the two methods was 52%. Five patients with positive aspiration findings on salivagram were negative on VFSS. The association between VFSS and salivagram findings was significant but the total agreement was 72%. The frequency of aspiration pneumonia was significantly associated with an abnormal salivagram finding.

CONCLUSIONS

A salivagram may be a useful method for the evaluation of aspiration in elderly people, and a combination of the VFSS and salivagram methods could enable a more effective investigation of aspiration pneumonia.

Pulmonary emergencies: pneumonia, acute respiratory distress syndrome, lung abscess, and empyema

This article describes the clinical presentation of pneumonia, acute respiratory distress syndrome, lung abscess, and empyema: life-threatening infections of the pulmonary system. The etiology and risk factors for each of these conditions are described, diagnostic approaches are discussed, and evidence-based management options are reviewed.

Effectiveness of oral hygiene interventions against oral and oropharyngeal reservoirs of aerobic and facultatively anaerobic gram-negative bacilli

BACKGROUND

Aerobic and facultatively anaerobic gram-negative bacilli (AGNB) are opportunistic pathogens and continue to cause a large number of hospital-acquired infections. AGNB residing in the oral cavity and oropharynx have been linked to nosocomial pneumonia and septicemia. Although AGNB are not considered members of the normal oral and oropharyngeal flora, medically compromised patients have been demonstrated to be susceptible to AGNB colonization.

METHODS

A literature search was conducted to retrieve articles that evaluated the effectiveness of oral hygiene interventions in reducing the oral and oropharyngeal carriage of AGNB in medically compromised patients.

RESULTS

Few studies have documented the use of mechanical oral hygiene interventions alone against AGNB. Although a number of studies have employed oral hygiene interventions complemented by antiseptic agents such as chlorhexidine and povidone iodine, there appears to be a discrepancy between their in vitro and in vivo effectiveness.

CONCLUSION

With the recognition of the oral cavity and oropharynx as a reservoir of AGNB and the recent emergence of multidrug and pandrug resistance in hospital settings, there is a pressing need for additional high-quality randomized controlled trials to determine which oral hygiene interventions or combination of interventions are most effective in eliminating or reducing AGNB carriage.

Pneumonia in the long-term resident

Pneumonia in the long-term resident is common. It is associated with high morbidity and mortality. However, diagnosis and management of pneumonia in long-term care residents is challenging. This article provides an overview of the epidemiology, pathophysiology, diagnostic challenges, and management recommendations for pneumonia in this setting.

Oral health promotion interventions on oral yeast in hospitalised and medically compromised patients: a systematic review

Yeast are major aetiological agents of localised oral mucosal lesions, and are also leading causes of nosocomial bloodstream infections. The purpose of this systematic review was to examine the effectiveness of oral health promotion interventions on the prevalence and incidence of these opportunistic oral pathogens in hospitalised and medically compromised patients. The PubMed, ISI Web of Science and Cochrane Library databases were searched for clinical trials assessing the effect of oral health promotion interventions on oral yeast. Chlorhexidine delivered in a variety of oral hygiene products appeared to have some effect on oral yeast, although some studies found equivocal effects. Although a wide array of other compounds have also been investigated, their clinical effectiveness remains to be substantiated. Likewise, the utility of mechanical oral hygiene interventions and other oral health promotion measures such as topical application of salivary substitute, remains unsettled. Although many chemical agents contained in oral hygiene products have proven in vitro activity against oral yeast, their clinical effectiveness and potential role as adjuncts or alternative therapies to conventional treatment remains to be confirmed by further high-quality randomised controlled trials. This is pertinent, given the recent emergence of yeast resistance to conventional antifungal agents.

How important is age in defining the prognosis of patients with community-acquired pneumonia?

PURPOSE OF REVIEW

Given that the population is increasing in age, a better understanding of the relationship between chronological age and health-related outcomes (especially mortality) is needed, for both chronic diseases (e.g. diabetes) and acute illnesses (e.g. pneumonia). Our purpose was to review the impact of age on the prognosis of patients with community-acquired pneumonia (CAP).

RECENT FINDINGS

Many studies in patients with CAP have suggested that chronological age is not necessarily independently associated with mortality. Poorer outcomes in the elderly with CAP have been related to severity of disease, comorbid disease burden, functional status, and frailty, but not to age alone. However, many of these studies suffer from 'over-adjustment' due to the use of unmodified severity scores such as the Pneumonia Severity Index or Acute Physiology and Chronic Health Evaluation II (that already include age) in multivariable analyses. Studies accounting for this over-adjustment suggest that age is, in fact, independently associated with mortality in hospitalized patients with CAP. Other outcomes including hospitalization and readmission rates, hospital length of stay, and cost of care are similarly associated with increasing age. Residual confounding is still a problem in many of the observational studies reviewed.

SUMMARY

Contrary to conventional wisdom, chronological age is independently associated with adverse outcomes in patients with CAP. Until better methods (or more clinically-rich datasets) for observational studies are developed that can avoid over-adjustment and better deal with residual confounding, physicians should take into account both a patient's overall health status and his or her chronological age.

Community-acquired pneumonia in the elderly

BACKGROUND

Community-acquired pneumonia (CAP) is a frequent cause of hospitalization and death among the elderly.

OBJECTIVE

This article reviews information on CAP among the elderly, including age-related changes, predisposing risk factors, causes, treatment strategies, and prevention.

METHODS

Searches of MEDLINE (January 1990-November 2009), International Pharmaceutical Abstracts (January 1990-November 2009), and Google Scholar were conducted using the terms community-acquired pneumonia, pneumonia, treatment guidelines, and elderly. Additional publications were found by searching the reference lists of the identified articles. Studies that reported diagnostic criteria as well as the treatment outcomes achieved in adult patients with CAP were selected for this review.

RESULTS

Three practice guidelines, 5 reviews, and 43 studies on CAP in the elderly were identified in the literature search. Based on those publications, risk factors that predispose the elderly to pneumonia include comorbid conditions, poor functional and nutritional status, consumption of alcohol, and smoking. The clinical presentation of pneumonia in the elderly (>/=65 years of age) may be subtle, lacking the typical acute symptoms (fever, cough, dyspnea, and purulent sputum) observed in younger adults. Pneumonia should be suspected in all elderly patients who have fever, altered mental status, or a sudden decline in functional status, with or without lower respiratory tract symptoms such as cough, purulent sputum, and dyspnea. Treatment of CAP in the elderly should be guided by the latest recommendations of the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS), along with consideration of local rates and patterns of antimicrobial resistance, as well as individual patient risk factors for acquiring less common or more resistant pathogens. Recommended empiric antimicrobial regimens generally consist of either a beta-lactam plus a macrolide or a respiratory fluoroquinolone alone. Adherence to the IDSA/ATS guidelines has been found to improve in-hospital mortality (adherence vs nonadherence, 8%; 95% CI, 7%-10% vs 17%; 95% CI, 14%-20%; P< 0.01), length of hospital stay (8 days; interquartile range [IQR], 5-15 vs 10 days; IQR, 6-24 days, respectively; P < 0.01), and time to clinical stability in elderly patients with CAP (percentage of stable patients by day 7, 71%; 95% CI, 68%-74% vs 57%; 95% CI, 53%-61%, respectively; P < 0.01). All elderly patients should be vaccinated against pneumococcal disease and influenza based on recommendations from the Centers for Disease Control and Prevention. Lifestyle modifications and nutritional support are also important elements in the prevention of pneumonia in the elderly.

CONCLUSION

Adherence to established guidelines, along with customization of antimicrobial therapy based on local rates and patterns of resistance and patient-specific risk factors, likely will improve the treatment outcome of elderly patients with CAP.

Diagnosis and management of oropharyngeal Dysphagia and its nutritional and respiratory complications in the elderly

Oropharyngeal dysphagia is a major complaint among older people. Dysphagia may cause two types of complications in these patients: (a) a decrease in the efficacy of deglutition leading to malnutrition and dehydration, (b) a decrease in deglutition safety, leading to tracheobronchial aspiration which results in aspiration pneumonia and can lead to death. Clinical screening methods should be used to identify older people with oropharyngeal dysphagia and to identify those patients who are at risk of aspiration. Videofluoroscopy (VFS) is the gold standard to study the oral and pharyngeal mechanisms of dysphagia in older patients. Up to 30% of older patients with dysphagia present aspiration-half of them without cough, and 45%, oropharyngeal residue; and 55% older patients with dysphagia are at risk of malnutrition. Treatment with dietetic changes in bolus volume and viscosity, as well as rehabilitation procedures can improve deglutition and prevent nutritional and respiratory complications in older patients. Diagnosis and management of oropharyngeal dysphagia need a multidisciplinary approach.

Aspiration syndromes: aspiration pneumonia and pneumonitis

Aspiration pneumonia and pneumonitis are common clinical syndromes that occur in hospitalized patients. Aspiration pneumonia occurs in patients with dysphagia and usually presents as a community-acquired pneumonia with a focal infiltrate in a dependent bronchopulmonary segment. Patients with aspiration pneumonia require treatment with broad-spectrum antibiotics and management of the underlying dysphagia. Aspiration pneumonitis follows the aspiration of gastric contents, usually in patients with a marked decreased level of consciousness. Treatment of aspiration pneumonitis is essentially supportive; however, corticosteroids and other immunomodulating agents may have a role in these patients.