Impact of oral care with versus without toothbrushing on the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials

Is Zero Ventilator-Associated Pneumonia Achievable? Updated Practical Approaches to Ventilator-Associated Pneumonia Prevention

Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions took pride in implementing effective VAP prevention bundles that combined at least head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. Spontaneous breathing and awakening trials have also consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP.

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.

Assessment of Nursing Staff's Knowledge, Attitude and Practice Regarding Oral Hygiene Care in Intensive Care Unit Patients: A Multicenter Cross-sectional Study

Background

Oral care is one of the fundamental nursing care procedures used to decrease oral colonization, dental plaque, respiratory infections, patient stay, and cost. The importance of good oral hygiene for patients in intensive care units (ICUs) is well recognized, however, the most effective way to achieve good oral care in the ICU is unclear. Therefore, the aim of this study was to assess the knowledge, attitude, and practice of nursing professionals regarding oral healthcare in ICUs among various medical institutes across India.

Materials and methods

A questionnaire-based multicentric cross-sectional survey was conducted among registered nursing professionals employed at ICUs of three government tertiary healthcare centers (THC) of India: THC-I, THC-II, and THC-III located in the eastern and northern parts of India between February 2022 and July 2022.

Results

A total of 150 nurses completed the questionnaire form (response rate: 62.5%) comprised of 49 (32.7%) males and 101 (67.3%) females with a mean age of 35.69 ± 7.7 years. Nursing officers' knowledge surpassed that of staff nurses regarding the duration of toothbrushing (p = 0.033). Among interinstitutional comparisons, THC-I nurses showed the greatest knowledge regarding the duration of toothbrushing and the mechanism of preventing saliva accumulation to reduce microbial growth (p = 0.013 and p = 0.003, respectively). Based on total work experience, participants were segregated into three groups: Group I (<7 years), group II (7.1-13.9 years), and group III (>14 years). Group II surpassed the knowledge of denture removal during sleep, cleaning after every meal, and storing in personalized air-tight containers (p = 0.001 and p = 0.036, respectively). The majority from group II recommended plain saline as the material for oral hygiene maintenance in ICU patients (p = 0.008). Group III predominantly practiced the ideal handwashing technique pre- and post-patient contact which was statistically significant (p = 0.001).

Conclusion

This study observed that a knowledge gap exists among the nurses of the three institutes across India pertaining to the oral hygiene care of ICU patients. Nurse's education and implementation of the proper oral hygiene measures for intubated patients in ICU setup is an essential need.

How to cite this article

Kumar S, Singh B, Mahuli AV, Kumar S, Singh A, Jha AK. Assessment of Nursing Staff's Knowledge, Attitude and Practice Regarding Oral Hygiene Care in Intensive Care Unit Patients: A Multicenter Cross-sectional Study. Indian J Crit Care Med 2024;28(1):48-57.

Does chlorhexidine reduce the incidence of ventilator-associated pneumonia in ICU patients? A systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate chlorhexidine's efficacy in preventing ventilator-associated pneumonia (VAP).

DESIGN

A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

SETTINGS

The data were obtained from Pubmed, Cochrane Library, and EMBASE.

PATIENTS OR PARTICIPANTS

Only mechanically ventilated patients for at least 48h were included.

INTERVENTIONS

Randomized clinical trials applying any dosage form of chlorhexidine were eligible.

MAIN VARIABLES OF INTEREST

The relative risk (RR) of the VAP incidence and all-cause mortality was assessed using the random-effects model. The mean difference in days of mechanical ventilation duration and intensive care unit (ICU) length of stay were also appraised.

RESULTS

Ten studies involving 1233 patients were included in the meta-analysis. The oral application of CHX reduced the incidence of VAP (RR, 0.73 [95% CI, 0.55, 0.97]) and did not show an increase in all-cause mortality (RR, 1.13 [95% CI, 0.96, 1.32]).

CONCLUSIONS

CHX proved effective to prevent VAP. However, a conclusion on mortality rates could not be drawn because the quality of the evidence was very low for this outcome.

Prevention of Pneumonia due to Ventilator in Critical Patients with U Shape Oral Hygiene Model: A Systematic Review

In critical patients, generally, microorganisms originating from nasal cause Ventilator-Associated Pneumonia (VAP). This systematic review was aimed to identify the toothbrush U shape model usage, in potentially decrease the prevalence of ventilator-associated pneumonia among patients in intensive care units. Search strategy identified 15 potentially eligible articles, were 7 RCTs, 4 Meta-analysis, and 4 Observational studies. A total of 15 studies demonstrated the use of toothbrushing and chlorhexidine in mechanically ventilator patients in preventing VAP. Ten studies found positive association between toothbrushing and the use of chlorhexidine in preventing VAP. However, there were 5 studies that did not reveal an additional decrease of VAP incidence either of CHX and only toothbrushing or combination thereof. We cautiously assumed that toothbrushing and chlorhexidine might reduce VAP but the implementation of brushing should be taken into reconsideration in the terms of maintaining it.

Oral care for intensive care unit patients without mechanical ventilation: protocol for a systematic review and meta-analysis

BACKGROUND

Infection is a common problem and a major cause of morbidity and mortality for patients in intensive care units (ICUs). According to published meta-analyses, oral care has been found to reduce the risk of nosocomial pneumonia, and has been recommended to improve the oral environment for patients in ICUs. However, relatively little information is available about the effects of oral care in patients without ventilatory support in ICUs. Therefore, this review proposes to evaluate the effectiveness of oral care in preventing pneumonia in non-ventilated ICU patients.

METHODS

Eight databases will be searched for relevant literature, including four Chinese and four English online databases, from their inception to the protocol publication date. Records obtained will be managed and screened via Endnote X7. All literature will be selected following pre-established inclusion criteria by two independent review authors to obtain quality trials. The quality of the included records will be evaluated according to the "risk of bias table", recommended by the Cochrane Handbook for Systematic Reviews of Interventions. All the data will be extracted by one author and checked by another. If there is any disagreement, a final agreement will be reached with a third reviewer via consultation. If there are missing data, the original authors will be emailed to ask for it. If enough data were collected, the data synthesis will be performed using Review Manager (RevMan5.3). Both a random effect model and a fixed effect model will be undertaken. A Bayesian meta-analysis will also be performed to estimate the magnitude of the heterogeneity variance and comparing it with the distribution using the WinBUGS software. Otherwise, the results will be reported narratively. The sources of heterogeneity will be determined using meta-regression and subgroup analysis if there is significant heterogeneity. A funnel plot will be used to assess publication bias if there are enough records included. The Cochrane Handbook for Systematic Reviews of Interventions will be followed throughout the system evaluation process.

CONCLUSION

This review will provide evidence of oral care for intensive care unit patients without mechanical ventilation to prevent nosocomial pneumonia.

TRIAL REGISTRATION

PROSPERO Research registration identifying number: CRD42020146932.

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.

Oral health care for the critically ill: a narrative review

Background

The link between oral bacteria and respiratory infections is well documented. Dental plaque has the potential to be colonized by respiratory pathogens and this, together with microaspiration of oral bacteria, can lead to pneumonia particularly in the elderly and critically ill. The provision of adequate oral care is therefore essential for the maintenance of good oral health and the prevention of respiratory complications.

Main body

Numerous oral care practices are utilised for intubated patients, with a clear lack of consensus on the best approach for oral care. This narrative review aims to explore the oral-lung connection and discuss in detail current oral care practices to identify shortcomings and offer suggestions for future research. The importance of adequate oral care has been recognised in guideline interventions for the prevention of pneumonia, but practices differ and controversy exists particularly regarding the use of chlorhexidine. The oral health assessment is also an important but often overlooked element of oral care that needs to be considered. Oral care plans should ideally be implemented on the basis of an individual oral health assessment. An oral health assessment prior to provision of oral care should identify patient needs and facilitate targeted oral care interventions.

Conclusion

Oral health is an important consideration in the management of the critically ill. Studies have suggested benefit in the reduction of respiratory complication such as Ventilator Associated Pneumonia associated with effective oral health care practices. However, at present there is no consensus as to the best way of providing optimal oral health care in the critically ill. Further research is needed to standardise oral health assessment and care practices to enable development of evidenced based personalised oral care for the critically ill.

Hospital Dentistry for Intensive Care Unit Patients: A Comprehensive Review

This study aimed to review the oral hygiene status, oral care guidelines, and outcomes of oral care in intensive care unit (ICU) patients from a dental perspective for effective oral care. A literature search using the keywords "Hospital dentistry" OR "Oral care" OR "Intensive care unit" OR "Hospital inpatient" OR "Hospitalization" OR "Emergency service" AND "Oral health" OR "Oral hygiene" OR "Dental plaque" was conducted in PubMed, Medline, and Google Scholar to identify publications reporting on the oral care of the patients admitted to ICUs. A total of 17,400 articles were initially identified. Of these, 58 were selected and classified into three categories for critical review. Seven of these studies evaluated the oral status of ICU patients, and most of the studies indicated that ICU patients had poor oral hygiene or required active dental treatment. Thirty-three of these studies evaluated oral care methods for ICU patients, and in general, oral care methods using chlorhexidine as adjuncts along with tooth brushing were recommended. However, there were insufficient studies to evaluate oral hygiene through effective assessment tools from a dental perspective. In 36 studies on the outcomes of oral care in ICU patients, interventions by dental professionals showed effective results in preventing hospital-acquired infection. This review highlights the importance of establishing guidelines for the evaluation of oral status in ICU patients and summarizes data that may be useful for future studies. Further studies on maintaining good oral hygiene among ICU patients are needed.

An umbrella review of systematic reviews of the evidence of a causal relationship between periodontal microbes and respiratory diseases: Position paper from the Canadian Dental Hygienists Association

Previous position papers have confirmed to varying degrees associations between periodontal microbes and respiratory tract infections such as nosocomial or hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and chronic obstructive pulmonary diseases (COPD). Causal relationships have not been confirmed and have been the source of much confusion for the medical and oral health professions.

Aim

To investigate whether sufficient evidence exists for a causal relationship between periodontal microbes and respiratory diseases, with a focus on HAP and VAP.

Methods

The PICO question was "For patients in hospitals, nursing homes or long-term care facilities who are at high risk for respiratory infections, will an oral care intervention such as toothbrushing, administration of antimicrobial agents, and/or professional care, as compared to no oral care intervention (or usual oral care) reduce the risk for respiratory infections?" Only systematic reviews (SRs) with or without a meta-analysis (MA) of randomized controlled trials published in the English language between 2007 and 2019 were included. Databases searched included PubMed, MEDLINE, EbscoHost, CINAHL, Scopus, Cochrane Registry of Systematic reviews, and Clinical Trials Registry. Quality assessments were conducted by both authors using the PRISMA checklist. The Bradford Hill criteria were used to determine evidence for causality.

Results

Of 47 respiratory studies retrieved, after elimination of duplicates and studies not meeting inclusion criteria, 10 SRs were selected, 9 of which included MAs. Although there was evidence that administration of chlorhexidine gluconate (CHX) reduced the risk for VAP, none existed for HAP. Limitations included inconsistencies among studies in population groups, CHX concentration, frequency of administration, number of applications, and insufficient evidence for use of povidone iodine or toothbrushing in ventilated patients. While some studies reported other patient-centred outcomes (i.e., ICU mortality, length of ICU stay or duration of mechanical ventilation), findings were positive only for cardiac surgery ventilated patients, who did not meet the inclusion criteria.

Conclusions

Bradford Hill criteria analysis failed to support a causal relationship between periodontal microbes/oral health care and respiratory diseases such as pneumonia.

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.

Is Zero Ventilator-Associated Pneumonia Achievable?: Practical Approaches to Ventilator-Associated Pneumonia Prevention

Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions implemented effective VAP prevention bundles that combined head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. More recently, spontaneous breathing and awakening trials have consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP. More recent data question the overall positive impact of prevention bundles, including some of their core component interventions.

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.

Impact of a VAP bundle in Belgian intensive care units

Background

In order to decrease the incidence of ventilator-associated pneumonia (VAP) in Belgium, a national campaign for implementing a VAP bundle involving assessment of sedation, cuff pressure control, oral care with chlorhexidine and semirecumbent position, was launched in 2011–2012. This report will document the impact of this campaign.

Methods

On 1 day, once a year from 2010 till 2016, except in 2012, Belgian ICUs were questioned about their ventilated patients. For each of these, data about the application of the bundle and the possible treatment for VAP were recorded.

Results

Between 36.6 and 54.8% of the 120 Belgian ICUs participated in the successive surveys. While the characteristics of ventilated patients remained similar throughout the years, the percentage of ventilated patients and especially the duration of ventilation significantly decreased before and after the national VAP bundle campaign. Ventilator care also profoundly changed: Controlling cuff pressure, head positioning above 30° were obtained in more than 90% of cases. Oral care was more frequently performed within a day, using more concentrated solutions of chlorhexidine. Subglottic suctioning also was used but in only 24.7% of the cases in the last years. Regarding the prevalence of VAP, it significantly decreased from 28% of ventilated patients in 2010 to 10.1% in 2016 (p ≤ 0.0001).

Conclusion

Although a causal relationship cannot be inferred from these data, the successive surveys revealed a potential impact of the VAP bundle campaign on both the respiratory care of ventilated patients and the prevalence of VAP in Belgian ICUs encouraging them to follow the guidelines.

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.

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.

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

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 < .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.

Year in review 2012: Critical Care--respiratory infections

Over the last two decades, considerable progress has been made in the understanding of disease mechanisms and infection control strategies related to infections, particularly pneumonia, in critically ill patients. Patient-centered and preventative strategies assume paramount importance in this era of limited health-care resources, in which effective targeted therapy is required to achieve the best outcomes. Risk stratification using severity scores and inflammatory biomarkers is a promising strategy for identifying sick patients early during their hospital stay. The emergence of multidrug-resistant pathogens is becoming a major hurdle in intensive care units. Cooperation, education, and interaction between multiple disciplines in the intensive care unit are required to limit the spread of resistant pathogens and to improve care. In this review, we summarize findings from major publications over the last year in the field of respiratory infections in critically ill patients, putting an emphasis on a newer understanding of pathogenesis, use of biomarkers, and antibiotic stewardship and examining new treatment options and preventive strategies.

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

BACKGROUND

Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in persons 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 OHC on the incidence of VAP in critically ill patients receiving mechanical ventilation in intensive care units (ICUs) in hospitals.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 14 January 2013), CENTRAL (The Cochrane Library 2012, Issue 12), MEDLINE (OVID) (1946 to 14 January 2013), EMBASE (OVID) (1980 to 14 January 2013), LILACS (BIREME) (1982 to 14 January 2013), CINAHL (EBSCO) (1980 to 14 January 2013), 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), OpenGrey and ClinicalTrials.gov (to 14 January 2013). There were no restrictions regarding language or date of publication.

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.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all search results, extracted data and undertook risk of bias. We contacted study authors for additional information. Trials with similar interventions and outcomes were pooled reporting odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes using random-effects models unless there were fewer than four studies.

MAIN 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.There is moderate quality evidence from 17 RCTs (2402 participants, two at high, 11 at unclear and four at low risk of bias) 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%). This is equivalent to a number needed to treat (NNT) of 15 (95% CI 10 to 34) indicating that for every 15 ventilated patients in intensive care receiving OHC including chlorhexidine, one outcome of VAP will be prevented. There is no evidence of a difference between CHX and placebo/usual care in the outcomes of mortality (OR 1.10, 95% CI 0.87 to 1.38, P = 0.44, I(2) = 2%, 15 RCTs, moderate quality evidence), duration of mechanical ventilation (MD 0.09, 95% CI -0.84 to 1.01 days, P = 0.85, I(2) = 24%, six RCTs, moderate quality evidence), or duration of ICU stay (MD -0.21, 95% CI -1.48 to 1.89 days, P = 0.81, I(2) = 9%, six RCTs, moderate quality evidence). 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.From three trials of children aged from 0 to 15 years (342 participants, moderate quality evidence) there is no evidence of a difference between OHC with CHX and placebo for the outcomes of VAP (OR 1.07, 95% CI 0.65 to 1.77, P = 0.79, I(2) = 0%), or mortality (OR 0.73, 95% CI 0.41 to 1.30, P = 0.28, I(2) = 0%), and insufficient evidence to determine the effect on the outcomes of duration of ventilation, duration of ICU stay, use of systemic antibiotics, plaque index, microbiological cultures or adverse effects, in children.Based on four RCTs (828 participants, low quality evidence) there is no evidence of a difference between OHC including toothbrushing (± CHX) compared to OHC without toothbrushing (± CHX) for the outcome of VAP (OR 0.69, 95% CI 0.36 to 1.29, P = 0.24 , I(2) = 64%) and no evidence of a difference for mortality (OR 0.85, 95% CI 0.62 to 1.16, P = 0.31, I(2) = 0%, four RCTs, moderate quality evidence). There is insufficient evidence to determine whether there is a difference due to toothbrushing for the outcomes of duration of mechanical ventilation, duration of ICU stay, use of systemic antibiotics, oral health indices, microbiological cultures, adverse effects, caregivers preferences or cost.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.

AUTHORS' 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.

Oral care and pulmonary infection - the importance of plaque scoring

Improving the quality of oral hygiene is recognised as an important counter measure for reducing the incidence of ventilator-associated pneumonia amongst critically ill patients. Toothbrushing physically disrupts the dental plaque that acts as a reservoir for pulmonary infection and therefore has the potential to reduce the incidence of ventilator-associated pneumonia. Gu and colleagues performed a systematic review and meta-analysis of oral hygiene with and without a toothbrush and found no difference in the incidence of pneumonia in mechanically ventilated patients. The diagnosis of ventilator-associated pneumonia is prone to bias and future studies of oral care interventions should focus on measures of oral cleanliness such as plaque and gingival scores. Once the optimal strategy for oral hygiene is defined in the critically ill, larger studies focussing on ventilator-associated pneumonia or mortality can be conducted.