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He Q, Peng Z, He C, Zhang C, Hu R. Effect of different mouthwashes on ventilator-related outcomes and mortality in intensive care unit patients: A network meta-analysis. Aust Crit Care 2024:S1036-7314(24)00205-4. [PMID: 39179488 DOI: 10.1016/j.aucc.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 06/04/2024] [Accepted: 06/23/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Ventilator-associated pneumonia is a common and life-threatening complication in intensive care unit (ICU) patients. Maintaining oral hygiene is crucial for reducing ventilator-associated pneumonia incidence. Various mouthwash solutions are used for oral care in ICU settings, but their comparative effectiveness remains unclear. This study aims to systematically evaluate and compare the efficacy and safety of commonly used mouthwashes for oral care in mechanically ventilated ICU patients. METHODS We searched PubMed, Web of Science, Embase, and Cochrane Library for randomised controlled trials (RCTs) comparing saline, chlorhexidine, sodium bicarbonate, oxidising agents, herbal extracts, and povidone-iodine for oral care in ventilated ICU patients. Outcomes included ventilator-associated pneumonia incidence, ICU mortality, duration of ventilation, and Escherichia coli fixed value. A network meta-analysis (NMA) was conducted to synthesise direct and indirect evidence. This study is registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols, 2023120028. RESULTS FourteenRCTs with 1644 participants were included. Oxidising agents showed a trend towards reducing the incidence of VAP compared to the control group (risk ratio: 0.24, 95% confidence interval: 0.05-1.10). Administration of saline was associated with a notable reduction in ICU mortality (risk ratio: 0.18, 95% confidence interval: 0.04-0.88) versus no mouthwash. No significant differences were observed in the duration of mechanical ventilation between chlorhexidine, povidone-iodine, and the control group. CONCLUSIONS Antimicrobial mouthwashes, especially chlorhexidine, pose potential risks in ICU patients; oxidising solutions demonstrate relative safety. Saline solution emerges as a promising alternative, associated with a significant reduction in mortality rates. However, the need for large, high-quality RCTs remains paramount to substantiate these findings and establish evidence-based oral-care protocols in ICU settings. REGISTRATION This study is registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols, 2023120028.
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Affiliation(s)
- Qianqian He
- Medical College, Hunan Normal University, No. 371 Tongzipo Road, Yuelu District, Changsha, Hunan, China.
| | - Zengjin Peng
- Medical College, Hunan Normal University, No. 371 Tongzipo Road, Yuelu District, Changsha, Hunan, China; Department of Internal Cardiovascular Medicine, The Second Xiangya Hospital of Central South University, No. 139 Middle Renmin Road, Furong District, Changsha, Hunan, China.
| | - Caiyun He
- Medical College, Hunan Normal University, No. 371 Tongzipo Road, Yuelu District, Changsha, Hunan, China.
| | - Chao Zhang
- Nursing Department, School of Nursing, Shandong University of Traditional Chinese Medicine, 16369 Jingshi Road, Lixia District, Jinan, Shandong 250014, China.
| | - Rong Hu
- Medical College, Hunan Normal University, No. 371 Tongzipo Road, Yuelu District, Changsha, Hunan, China.
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Ashford JR. Impaired oral health: a required companion of bacterial aspiration pneumonia. FRONTIERS IN REHABILITATION SCIENCES 2024; 5:1337920. [PMID: 38894716 PMCID: PMC11183832 DOI: 10.3389/fresc.2024.1337920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 05/20/2024] [Indexed: 06/21/2024]
Abstract
Laryngotracheal aspiration has a widely-held reputation as a primary cause of lower respiratory infections, such as pneumonia, and is a major concern of care providers of the seriously ill orelderly frail patient. Laryngeal mechanical inefficiency resulting in aspiration into the lower respiratory tract, by itself, is not the cause of pneumonia. It is but one of several factors that must be present simultaneously for pneumonia to develop. Aspiration of oral and gastric contentsoccurs often in healthy people of all ages and without significant pulmonary consequences. Inthe seriously ill or elderly frail patient, higher concentrations of pathogens in the contents of theaspirate are the primary catalyst for pulmonary infection development if in an immunocompromised lower respiratory system. The oral cavity is a complex and ever changing eco-environment striving to maintain homogeneity among the numerous microbial communities inhabiting its surfaces. Poor maintenance of these surfaces to prevent infection can result inpathogenic changes to these microbial communities and, with subsequent proliferation, can altermicrobial communities in the tracheal and bronchial passages. Higher bacterial pathogen concentrations mixing with oral secretions, or with foods, when aspirated into an immunecompromised lower respiratory complex, may result in bacterial aspiration pneumonia development, or other respiratory or systemic diseases. A large volume of clinical evidence makes it clear that oral cleaning regimens, when used in caring for ill or frail patients in hospitals and long-term care facilities, drastically reduce the incidence of respiratory infection and death. The purpose of this narrative review is to examine oral health as a required causative companionin bacterial aspiration pneumonia development, and the effectiveness of oral infection control inthe prevention of this disease.
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De Cassai A, Pettenuzzo T, Busetto V, Legnaro C, Pretto C, Rotondi A, Boscolo A, Sella N, Munari M, Navalesi P. Chlorhexidine is not effective at any concentration in preventing ventilator-associated pneumonia: a systematic review and network meta-analysis. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:30. [PMID: 38702835 PMCID: PMC11067293 DOI: 10.1186/s44158-024-00166-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Oral chlorhexidine has been widely used for ventilator-associated pneumonia prevention in the critical care setting; however, previous studies and evidence synthesis have generated inconsistent findings. Our study aims to investigate if different concentrations of oral chlorhexidine may be effective in preventing such complication in intensive care unit patients. METHODS After pre-registration (Open Science Framework: 8CUKF), we conducted a network meta-analysis with the following PICOS: adult patients (age > 18 years old) undergoing invasive mechanical ventilation admitted in ICU (P); any concentration of chlorhexidine used for oral hygiene (I); placebo, sham intervention, usual care, or no intervention (C); rate of VAP (primary outcome), mechanical ventilation length, ICU length of stay (LOS), hospital LOS, mortality (secondary outcomes) (O); randomized controlled trials (S). We used the following database: PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and EMBASE without any limitation in publication date or language. RESULTS Chlorhexidine did not demonstrate any significant advantage over the control group in preventing ventilator-associated pneumonia or reducing mortality, duration of mechanical ventilation, length of stay in the intensive care unit, or overall mortality. CONCLUSIONS Chlorhexidine oral decontamination does not reduce the rate of ventilator-associated pneumonia in critically ill adult patients and its routine use could not be recommended. TRIAL REGISTRATION Registration number: Open Science Framework: 8CUKF.
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Affiliation(s)
- Alessandro De Cassai
- Sant'Antonio Anesthesia and Intensive Care Unit, University Hospital of Padua, Padua, Italy.
| | - Tommaso Pettenuzzo
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
| | - Veronica Busetto
- Cardiac Surgery Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | | | - Chiara Pretto
- Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Alessio Rotondi
- Department of Medicine - DIMED, University of Padova, Padua, Italy
| | - Annalisa Boscolo
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
- Department of Medicine - DIMED, University of Padova, Padua, Italy
- Thoracic Surgery and Lung Transplant Unit - Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Nicolò Sella
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
| | - Marina Munari
- Sant'Antonio Anesthesia and Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Paolo Navalesi
- UOC Anesthesia and Intensive Care Unit, University Hospital of Padova, Padua, Italy
- Department of Medicine - DIMED, University of Padova, Padua, Italy
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Katkowska M, Garbacz K, Kwapisz E, Suligowska K, Kusiak A, Cichońska D, Świetlik D. High oral carriage of multidrug resistant Gram-negative bacilli in adolescents: the SOPKARD-Junior study. Front Cell Infect Microbiol 2023; 13:1265777. [PMID: 38035342 PMCID: PMC10687414 DOI: 10.3389/fcimb.2023.1265777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction The colonization of the oral cavity by potentially pathogenic antimicrobial-resistant bacteria in adolescents and its consequences is very poorly understood. The present study focused on the occurrence of oral colonization by Gram-negative bacilli (GNB) and their multidrug resistance, including the production of extended-spectrum β-lactamases (ESBLs) and carbapenemases, among healthy adolescents and risk factors associated with GNB colonization. Materials and methods This study was conducted as part of "A program for the early detection of risk factors for lifestyle diseases SOPKARD-Junior" (SOPKARD-Junior). Oral samples were collected from 182 adolescents from four public elementary schools in Sopot, Poland, aged 13-14 years. Bacterial strains were identified by the MALDI-TOF MS method. Screening of antimicrobial resistance was performed using a disk diffusion method. The NG-Test® CARBA-5 was used to detect and differentiate the five most widely distributed carbapenemases. Demographic and clinical data were collected and statistical analysis of risk factors was performed. Results A total of 68 out of 182 (37.4%) healthy adolescents was documented oral colonization with Gram-negative bacilli, including 50/182 (27.5%) multidrug resistant (MDR-GNB) strains. Over 60% of oral carriage concerned three main genera Enterobacter spp., Pseudomonas spp., and Serratia spp., which were detected in 22.1%, 19.1%, and 19.1% of participants, respectively. Citrobacter spp., Escherichia coli, Klebsiella spp., Hafnia spp., Aeromonas spp., Acinetobacter spp., and Stenotrophomonas spp. were also isolated. The antimicrobial resistance to ampicillin (100%), ceftazidime (69.1%), meropenem (60.3%), gentamycin (60.3%), piperacillin/tazobactam (52.9%), and piperacillin (45.6%) were the most common. Among 73.5% GNB strains multidrug resistance was observed, including all Pseudomonas spp. strains. Among MDR-GNB, 30.4% were resistant to four groups of antibiotics, half of the MDR Pseudomonas spp. strains were resistant to 10 groups of antibiotics. Extended-spectrum β-lactamases were produced by Enterobacter cloacae, Klebsiella spp., and Serratia spp. (7.4%). Colonization by ESBLs-positive GNB strains was significantly associated with recurrent respiratory infections, nasal congestion, and bronchitis (p<0.05). Conclusion Our study revealed high oral carriage of multi-drug resistant Gram-negative bacilli in healthy adolescents and the association of ESBL-producing strains with respiratory infections. Further studies on oral colonization with GNB are necessary due to the possibility of distinct infections and the acquisition of antibiotic resistance by resident microbiota.
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Affiliation(s)
- Marta Katkowska
- Department of Oral Microbiology, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Garbacz
- Department of Oral Microbiology, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Ewa Kwapisz
- Department of Oral Microbiology, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Klaudia Suligowska
- Department of Dental Techniques and Masticatory System Dysfunctions, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
- Department of Preventive Medicine and Education, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Aida Kusiak
- Department of Periodontology and Oral Mucosa Diseases, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Dominika Cichońska
- Department of Periodontology and Oral Mucosa Diseases, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Dariusz Świetlik
- Division of Biostatistics and Neural Networks, Medical University of Gdansk, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
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Causey C, El Karim I, Blackwood B, McAuley DF, Lundy FT. Quantitative oral health assessments in mechanically ventilated patients: A scoping review. Nurs Crit Care 2023; 28:756-772. [PMID: 35771584 DOI: 10.1111/nicc.12789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/12/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Oral health is a key contributor to a person's overall health. Previous studies indicate that oral health deteriorates throughout ventilation and may contribute to the development of ventilator-associated pneumonia (VAP). Oral health at the time of initial ventilation may impact on this deterioration. AIMS To determine the quantitative clinical assessment methods used to measure oral health and what is currently known regarding the oral health of patients at the time of initial ventilation. STUDY DESIGN A systematic literature search using electronic bibliographic databases MEDLINE/PubMed, Embase, CINAHL, and the Cochrane Library was undertaken for this scoping review. Studies were included if patients were >18 years old and mechanically ventilated for <48 h at the time of the first oral assessment. RESULTS In total, 12 studies were included. The review demonstrates a limited understanding of clinical oral health at the time of initial ventilation. Significant variation in both assessment methods and reporting of oral health makes comparison of results difficult resulting in a poor overall understanding of oral health at the time of intubation. CONCLUSION Standardized assessment and reporting methods may improve clinical application of findings and help direct future research. We suggest developing a core outcome set to ensure consistent use of assessment tools as well as standardized reporting of results. RELEVANCE TO CLINICAL PRACTICE It is essential that a good understanding of oral health at the time of initial ventilation is gained so that patients receive more targeted oral hygiene intervention in ICU, potentially leading to improved patient outcomes.
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Affiliation(s)
- Christine Causey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - Ikhlas El Karim
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - Fionnuala T Lundy
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
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Cruz JC, Martins CK, Piassi JEV, Garcia Júnior IR, Santiago Junior JF, Faverani LP. Does chlorhexidine reduce the incidence of ventilator-associated pneumonia in ICU patients? A systematic review and meta-analysis. Med Intensiva 2023; 47:437-444. [PMID: 36464582 DOI: 10.1016/j.medine.2022.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE This study aimed to investigate chlorhexidine's efficacy in preventing ventilator-associated pneumonia (VAP). DESIGN A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. SETTINGS The data were obtained from Pubmed, Cochrane Library, and EMBASE. PATIENTS OR PARTICIPANTS Only mechanically ventilated patients for at least 48h were included. INTERVENTIONS Randomized clinical trials applying any dosage form of chlorhexidine were eligible. MAIN VARIABLES OF INTEREST The relative risk (RR) of the VAP incidence and all-cause mortality was assessed using the random-effects model. The mean difference in days of mechanical ventilation duration and intensive care unit (ICU) length of stay were also appraised. RESULTS Ten studies involving 1233 patients were included in the meta-analysis. The oral application of CHX reduced the incidence of VAP (RR, 0.73 [95% CI, 0.55, 0.97]) and did not show an increase in all-cause mortality (RR, 1.13 [95% CI, 0.96, 1.32]). CONCLUSIONS CHX proved effective to prevent VAP. However, a conclusion on mortality rates could not be drawn because the quality of the evidence was very low for this outcome.
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Affiliation(s)
- J C Cruz
- University of São Paulo (USP), Ribeirão Preto, Brazil.
| | - C K Martins
- Department of Medicine, University of Ribeirão Preto (UNAERP), Ribeirão Preto, Brazil
| | - J E V Piassi
- Division of Oral and Maxillofacial Surgery, Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil
| | - I R Garcia Júnior
- Division of Oral and Maxillofacial Surgery, Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil
| | - J F Santiago Junior
- Department of Health Sciences. Dentistry Course, Unisagrado: Centro Universitário Sagrado Coração, Bauru, SP, Brazil
| | - L P Faverani
- Division of Oral and Maxillofacial Surgery, Department of Diagnosis and Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil
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7
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Fu LS, Zhu LM, Yang YP, Lin L, Yao LQ. Impact of oral care modalities on the incidence of ventilator-associated pneumonia in the intensive care unit: A meta-analysis. Medicine (Baltimore) 2023; 102:e33418. [PMID: 37000078 PMCID: PMC10063266 DOI: 10.1097/md.0000000000033418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND At present, evidence of the role of oral hygiene in ICU-related pneumonia is rare. The study aimed to evaluate the effectiveness of toothbrush-based oral care in preventing ventilator-associated pneumonia (VAP) in patients with mechanical ventilation in the ICU. METHODS Ten databases were searched for randomized controlled trials (RCTs) evaluating toothbrush-based oral care for preventing VAP in patients with mechanical ventilation in ICU. Quality assessment and data extraction were independently performed by 2 researchers. The meta-analysis was performed using RevMan 5.3 software. RESULTS Thirteen RCTs with 657 patients were included. Tooth brushing + 0.2%/0.12% chlorhexidine was associated with reduced incidence of VAP compared to chlorhexidine (OR = 0.63, 95% confidence interval [CI]: 0.43-0.91, P = .01) or tooth brushing + placebo (OR = 0.47, 95% CI: 0.25-0.86, P = .02) in patients with mechanical ventilation in ICU, but was similar to cotton wipe with 0.2% or 0.12% chlorhexidine (OR = 1.33, 95% CI: 0.77-2.29, P = .31). CONCLUSIONS Tooth brushing combined with chlorhexidine mouthwash can prevent VAP in patients with mechanical ventilation in ICU. There is no advantage of tooth brushing combined with chlorhexidine mouthwash over cotton wipe with chlorhexidine mouthwash for preventing VAP in these patients.
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Affiliation(s)
- Li-Sang Fu
- The Affiliated Hospital of Putian University, Putian, Fujian Province, China
| | - Li-Mei Zhu
- The Affiliated Hospital of Putian University, Putian, Fujian Province, China
| | - Yuan-Ping Yang
- The Affiliated Hospital of Putian University, Putian, Fujian Province, China
| | - Ling Lin
- The Affiliated Hospital of Putian University, Putian, Fujian Province, China
| | - Li-Qun Yao
- Charles Darwin University, Faculty of Health, Brisbane Centre, Australia
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8
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Ardila CM, Bedoya-García JA. Bacterial resistance to antiseptics used in dentistry: A systematic scoping review of randomized clinical trials. Int J Dent Hyg 2023; 21:141-148. [PMID: 36269218 DOI: 10.1111/idh.12629] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/29/2022] [Accepted: 10/19/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To evaluate the prevalence and proportions of bacteria resistant to antiseptics used in dentistry. METHODS A review of randomized clinical trials (RCTs) was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews involving different databases. MeSH terms and keywords were provided to examine only RCTs with antiseptic-resistant results. RESULTS Five RCTs were included. These investigations analysed 442 patients. Concerning the prevalence and proportion of species resistant to antiseptics, it was found that the chlorhexidine group showed a statistically significant increase in Streptococcus mutans and Lactobacillus acidophilus counts indicating bacterial resistance (p < 0.001). Moreover, Veillonella species showed resistance to triclosan at the commencement and during the RCTs, and a slight increase in the proportion of resistant strains was observed. Porphyromonas gingivalis, Staphylococcus aureus, and Pseudomonas aeruginosa did not show resistance to cetylpyridinium chloride. Similarly, it was no observed resistance to medicinal herbal plant formulations. CONCLUSIONS Resistance of S. mutans and L. acidophilus to chlorhexidine was observed, this resistance increased during the follow-up period. Similarly, although in a slight proportion, an increase in the resistance of Veillonella spp. to triclosan during the study period was also described. No microorganisms resistance was observed to any of the other antiseptics studied.
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Affiliation(s)
- Carlos M Ardila
- Universidad de Antioquia U de A, Medellín, Colombia.,Biomedical Stomatology Research Group, Universidad de Antioquia U de A, Medellín, Colombia
| | - Jader Alexander Bedoya-García
- Universidad de Antioquia U de A, Medellín, Colombia.,Biomedical Stomatology Research Group, Universidad de Antioquia U de A, Medellín, Colombia
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Xiang Y, Ren X, Xu Y, Cheng L, Cai H, Hu T. Anti-Inflammatory and Anti-Bacterial Effects of Mouthwashes in Intensive Care Units: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:733. [PMID: 36613055 PMCID: PMC9819176 DOI: 10.3390/ijerph20010733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/25/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
Mouthwashes are used as oral care for critical care patients to prevent infections. However, there are conflicting data concerning whether mouthwashes are needed as a part of daily oral care for critical care patients. This study aimed to evaluate the anti-inflammatory and anti-bacterial effects of mouthwashes for critical care patients. The PubMed, EMBASE, CENTRAL, and grey literature databases were searched by descriptors combining population (intensive care unit patients) and intervention (mouthwashes). After the screening, only randomized controlled trials (RCTs) evaluating the anti-inflammatory and anti-bacterial effects of mouthwashes in patient critical care were included. From the 1531 articles, 16 RCTs satisfied the eligibility criteria for systematic review and 10 were included in the meta-analyses. A significant difference was found in the incidence of ventilator associated pneumonia (VAP) (odds ratio [OR] 0.53, 95% confidential interval [95% CI] 0.33 to 0.86) between the mouthwash and placebo groups, while no significant difference was found in the mortality (OR 1.49, 95%CI 0.92 to 2.40); the duration of mechanical ventilation (weighted mean difference [WMD] -0.10, 95%CI -2.01 to 1.81); and the colonization of Staphylococcus aureus (OR 0.88, 95%CI 0.34 to 2.30), Escherichia coli (OR 1.19, 95%CI 0.50 to 2.82), and Pseudomonas aeruginosa (OR 1.16, 95%CI 0.27 to 4.91) between the two groups. In conclusion, mouthwashes were effective in decreasing the incidence of VAP. Thus, mouthwashes can be used as part of daily oral care for critical care patients.
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Affiliation(s)
| | | | | | | | - He Cai
- Correspondence: (H.C.); (T.H.); Tel.: +86-028-8550-3486 (H.C.); +86-028-8550-3486 (T.H.)
| | - Tao Hu
- Correspondence: (H.C.); (T.H.); Tel.: +86-028-8550-3486 (H.C.); +86-028-8550-3486 (T.H.)
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10
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Chen YC, Ku EN, Tsai PF, Ng CM, Wang JL, Lin CW, Ko NY, Chang YJ. Effect of 0.12% Chlorhexidine Oral Rinse on Preventing Hospital-Acquired Pneumonia in Nonventilator Inpatients. J Nurs Res 2022; 30:e248. [PMID: 36201607 DOI: 10.1097/jnr.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Yen-Chin Chen
- PhD, RN, Assistant Head Nurse, Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, and Clinical Assistant Professor, Department of Nursing, College of Medicine, National Cheng Kung University, Taiwan
| | - En-Ni Ku
- MS, RN, Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Fang Tsai
- BS, MT, Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan
| | - Cheng-Man Ng
- MS, Research Assistant, Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan, and Department of Nursing, College of Medicine, National Cheng Kung University, Taiwan
| | - Jiun-Ling Wang
- MD, Associate Professor, Department of Medicine, College of Medicine, National Cheng Kung University, Taiwan
| | - Che-Wei Lin
- PhD, Assistant Professor, Department of Biomedical Engineering, College of Medicine, National Cheng Kung University, Taiwan
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11
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Yang L, Zhang Q, Zhai H. Comparative efficacy of different concentrations of chlorhexidine for prevention of
ventilator‐associated
pneumonia in intensive care units: A systematic review and network
meta‐analysis. Nurs Crit Care 2022. [DOI: 10.1111/nicc.12849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Li Yang
- The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University Lianyungang China
| | - Qin Zhang
- The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University Lianyungang China
| | - Huaixiang Zhai
- The First People's Hospital of Lianyungang, The First Affiliated Hospital of Kangda College of Nanjing Medical University Lianyungang China
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12
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Ardila CM, Bedoya-García JA. Microbial resistance to oral antiseptics used in hospitalized patients: A systematic scoping review of randomized clinical trials. SPECIAL CARE IN DENTISTRY 2022. [PMID: 36181674 DOI: 10.1111/scd.12781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate the prevalence and proportions of bacteria resistant to oral antiseptics used in hospitalized patients. METHODS AND RESULTS A review of randomized clinical trials (RCTs) was led by implementing the PRISMA extension for scoping reviews including various databases. MeSH terms and keywords were used to assess only RCTs with antiseptic-resistant outcomes. Fourth RCTs met the selection criteria. These trials studied 399 hospitalized patients for respiratory infections or cardiovascular disease. Methicillin-resistant Staphylococcus aureus and Acinetobacter baumannii were predominant pathogens in the chlorhexidine group. It was found that Veillonella parvula and Campylobacter gracilis (57% of the isolates) had resistance to triclosan, while 67% of Pseudomonas, Acinetobacter, and Enterobacter species presented resistance to chlorhexidine. However, an increase in minimal inhibitory concentrations of triclosan or chlorhexidine during the follow-up period was not observed. Moreover, chlorhexidine reduced the amount of S. aureus in dental plaque and the oropharyngeal colonization by aerobic microorganisms; nonetheless, it was unsatisfactory to decrease the occurrence of respiratory infections. No adverse events were reported. CONCLUSIONS Resistance of V. parvula and C. gracilis to triclosan, and Pseudomonas, Acinetobacter, and Enterobacter species to chlorhexidine were perceived. However, these resistances did not increase during the follow-up period.
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Affiliation(s)
- Carlos-M Ardila
- Universidad de Antioquia U de A, Medellín, Colombia.,Biomedical Stomatology Research Group, Universidad de Antioquia U de A, Medellín, Colombia
| | - Jader Alexander Bedoya-García
- Biomedical Stomatology Research Group, Universidad de Antioquia U de A, Medellín, Colombia.,Universidad de Antioquia U de A, Medellín, Colombia
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Dai W, Lin Y, Yang X, Huang P, Xia L, Ma J. Meta-Analysis of the Efficacy and Safety of Chlorhexidine for Ventilator-Associated Pneumonia Prevention in Mechanically Ventilated Patients. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:5311034. [PMID: 35942379 PMCID: PMC9356777 DOI: 10.1155/2022/5311034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/17/2022]
Abstract
Objective To explore the efficacy and safety of chlorhexidine oral care in the prevention of ventilator-associated pneumonia (VAP) by means of meta-analysis. Methods Randomized controlled trials on the effect of chlorhexidine oral care on the incidence of VAP in patients on mechanical ventilation were searched in PubMed, Scopus, Cochrane Library, and Embase from May 1, 2022. Two researchers independently screened and included the study, extracted the data, and evaluated the literature quality. RevMan5.3 software was used for meta-analysis. Results Meta-analysis of 13 included literature studies involving 1533 patients showed that oral care with chlorhexidine solution could reduce the incidence of VAP in patients with mechanical ventilation and the difference was statistically significant (RR = 0.61, 95% CI (0.46, 0.82), P=0.04). However, the results showed that the incidence of VAP of low concentration (0.02%, 0.12%, and 0.2%) and high concentration (2%) of chlorhexidine in the intervention group was lower than that in the control group and the difference was statistically significant (RR = 0.70, 95% CI (0.51, 0.96), P=0.03; RR = 0.41, 95% CI (0.27, 0.62)). There was no significant difference in mortality between the two groups (RR = 1.01, 95% CI (0.85, 1.21), P=0.87). There was no statistical significance in days ventilated or days in ICU between the two groups (RR = -0.02, 95% CI (-0.19, 0.16), P=0.84; RR = 0.01, 95% CI (-0.11, 0.14), P=0.85). Conclusion Existing evidence shows that chlorhexidine used for oral care of patients with mechanical ventilation can reduce the incidence of VAP, and high concentration of chlorhexidine (2%) or low concentration of chlorhexidine (0.02%, 0.12%, 0.2%) has a significant effect on the prevention of VAP. Considering the safety of clinical application, it is recommended to use 0.02%, 0.12%, and 0.2% chlorhexidine solution for oral care.
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Affiliation(s)
- Weiying Dai
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yao Lin
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiangying Yang
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Pei Huang
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Liuqin Xia
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jianping Ma
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Triamvisit S, Wongprasert W, Puttima C, Chiangmai MN, Thienjindakul N, Rodkul L, Jetjumnong C. Effect of modified care bundle for prevention of ventilator-associated pneumonia in critically-ill neurosurgical patients. Acute Crit Care 2022; 36:294-299. [PMID: 35263824 PMCID: PMC8907469 DOI: 10.4266/acc.2021.00983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Care bundles for ventilator-associated pneumonia (VAP) have been shown to minimize the rate of VAP in critically ill patients. Standard care bundles may need to be modified in resource-constrained situations. The goal of this study was to see if our modified VAP-care bundles lowered the risk of VAP in neurosurgical patients. Methods: A prospective cohort study was conducted in mechanically ventilated neurosurgical patients. The VAP bundle was adjusted in the cohort group by increasing the frequency of intermittent endotracheal tube cuff pressure monitoring to six times a day while reducing oral care with 0.12% chlorhexidine to three times a day. The rate of VAP was compared to the historical control group. Results: A total of 146 and 145 patients were enrolled in control and cohort groups, respectively. The mean age of patients was 52±16 years in both groups (P=0.803). The admission Glasgow coma scores were 7.79±2.67 and 7.80±2.77 in control and cohort group, respectively (P=0.969). VAP was found in nine patients in control group but only one patient in cohort group. The occurrence rate of VAP was significantly reduced in cohort group compared to control group (0.88/1,000 vs. 6.84/1,000 ventilator days, P=0.036). Conclusions: The modified VAP bundle is effective in lowering the VAP rate in critically ill neurosurgical patients. It requires low budget and manpower and can be employed in resource-constrained settings.
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Affiliation(s)
| | | | | | | | | | - Laksika Rodkul
- Division of Nursing, Chiang Mai University Hospital, Chiang Mai, Thailand
| | - Chumpon Jetjumnong
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Effect of 0.12% Chlorhexidine Use for Oral Care on Ventilator-Associated Respiratory Infections: A Randomized Controlled Trial. J Trauma Nurs 2021; 28:228-234. [PMID: 34210941 DOI: 10.1097/jtn.0000000000000590] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evidence suggests that the effect of 0.12% chlorhexidine (CHX) use for oral care on the development of ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT) is lacking. Evidence-based approaches to the prevention of VAP and VAT are of paramount importance for improving patients' outcomes. OBJECTIVES This study aimed to (1) compare the effect of 0.12% CHX use for oral care on preventing VAP and VAT with the placebo group, as well as (2) compare its effect on oral health and prevention of oral microbial colonization with the placebo group. METHODS Prospective, single-blinded, randomized controlled trial performed in 2 intensive care units at a hospital. The sample comprised 57 mechanically ventilated adults randomly allocated to the 0.12% CHX group and the placebo group. Barnason's oral assessment guide was used to evaluate the oral health of both groups before oral care during the first 24 hr of tracheal intubation (Day 0) and at Day 2 and Day 3. Oropharyngeal secretion, endotracheal tube aspirate, and nonbronchoscopic bronchoalveolar lavage samples were collected on Day 0 and Day 3. RESULTS The rate of VAT development was not statistically different between the groups (p = .318). However, a significant difference existed in the rate of VAP development (p = .043). The frequency of oropharyngeal colonization significantly decreased in the 0.12% CHX group compared with the placebo group at Day 3 (p = .001). CONCLUSION The use of 0.12% CHX for oral care could be effective for VAP prevention and reducing microbial colonization in mechanically ventilated patients.
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Pathak JL, Yan Y, Zhang Q, Wang L, Ge L. The role of oral microbiome in respiratory health and diseases. Respir Med 2021; 185:106475. [PMID: 34049183 DOI: 10.1016/j.rmed.2021.106475] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 12/16/2022]
Abstract
The oral cavity (mouth) has various microbial habitats, including, teeth, gingival sulcus, gingiva, tongue, inner cheek, hard palate, and soft palate. The human oral cavity houses the second most diverse microbiome in the body harboring over 700 bacterial species. The fine-tuned equilibrium of the oral microbiome ecosystem maintains oral health. Oral dysbiosis caused by food habits and poor oral hygiene leads to various oral diseases such as periodontitis, caries, gingivitis, and oral cancer. Recent advances in technology have revealed the correlation between the oral microbiome and systemic diseases such as pulmonary diseases, cardiovascular diseases, rheumatoid arthritis, Alzheimer's disease, and other metabolic diseases. Since the oral cavity directly connects with the upper respiratory tract, the oral microbiome has easier access to the respiratory system compared to other organ systems. Direct aspiration of oral microflora in the respiratory system and oral dysbiosis-induced host immune reaction and inflammation are mainly responsible for various pulmonary complications. Numbers of literature have reported the correlation between oral diseases and pulmonary diseases, suggesting the possible role of the oral microbiome in respiratory diseases such as chronic obstructive pulmonary diseases, pneumonia, lung cancer, etc. This paper reviews the current evidence in establishing a link between the oral microbiome and pulmonary diseases. We also discuss future research directions focusing on the oral microbiome to unravel novel therapeutic approaches that could prevent or treat the various pulmonary complications.
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Affiliation(s)
- Janak L Pathak
- Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Institute of Oral Disease, Guangzhou Medical University, Guangzhou, China
| | - Yongyong Yan
- Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Institute of Oral Disease, Guangzhou Medical University, Guangzhou, China
| | - Qingbin Zhang
- Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Institute of Oral Disease, Guangzhou Medical University, Guangzhou, China
| | - Liping Wang
- Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Institute of Oral Disease, Guangzhou Medical University, Guangzhou, China.
| | - Linhu Ge
- Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Institute of Oral Disease, Guangzhou Medical University, Guangzhou, China.
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17
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Presence of non-oral bacteria in the oral cavity. Arch Microbiol 2021; 203:2747-2760. [PMID: 33791834 PMCID: PMC8012020 DOI: 10.1007/s00203-021-02300-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/20/2020] [Accepted: 03/22/2021] [Indexed: 12/30/2022]
Abstract
A homeostatic balance exists between the resident microbiota in the oral cavity and the host. Perturbations of the oral microbiota under particular conditions can contribute to the growth of non-oral pathogens that are hard to kill because of their higher resistance to antimicrobials, raising the probability of treatment failure and reinfection. The presence of these bacteria in the oral cavity has been proven to be associated with several oral diseases such as periodontitis, caries, and gingivitis, and systemic diseases of importance in clinical medicine such as cystic fibrosis, HIV, and rheumatoid arthritis. However, it is still controversial whether these species are merely transient members or unique to the oral cavity. Mutualistic and antagonistic interactions between the oral microbiota and non-oral pathogens can also occur, though the mechanisms used by these bacteria are not clear. Therefore, this review presents an overview of the current knowledge about the presence of non-oral bacteria in the oral cavity, their relationship with systemic and oral diseases, and their interactions with oral bacteria.
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Zhao T, Wu X, Zhang Q, Li C, Worthington HV, Hua F. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev 2020; 12:CD008367. [PMID: 33368159 PMCID: PMC8111488 DOI: 10.1002/14651858.cd008367.pub4] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in people who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, swab, toothbrush, or combination, together with suction of secretions, may reduce the risk of VAP in these patients. OBJECTIVES To assess the effects of oral hygiene care (OHC) on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs). SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 25 February 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 1), MEDLINE Ovid (1946 to 25 February 2020), Embase Ovid (1980 to 25 February 2020), LILACS BIREME Virtual Health Library (1982 to 25 February 2020) and CINAHL EBSCO (1937 to 25 February 2020). We also searched the VIP Database (January 2012 to 8 March 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, gel, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data and assessed risk of bias in included studies. We contacted study authors for additional information. We reported risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, using the random-effects model of meta-analysis when data from four or more trials were combined. MAIN RESULTS We included 40 RCTs (5675 participants), which were conducted in various countries including China, USA, Brazil and Iran. We categorised these RCTs into five main comparisons: chlorhexidine (CHX) mouthrinse or gel versus placebo/usual care; CHX mouthrinse versus other oral care agents; toothbrushing (± antiseptics) versus no toothbrushing (± antiseptics); powered versus manual toothbrushing; and comparisons of other oral care agents used in OHC (other oral care agents versus placebo/usual care, or head-to-head comparisons between other oral care agents). We assessed the overall risk of bias as high in 31 trials and low in two, with the rest being unclear. Moderate-certainty evidence from 13 RCTs (1206 participants, 92% adults) shows that CHX mouthrinse or gel, as part of OHC, probably reduces the incidence of VAP compared to placebo or usual care from 26% to about 18% (RR 0.67, 95% confidence intervals (CI) 0.47 to 0.97; P = 0.03; I2 = 66%). This is equivalent to a number needed to treat for an additional beneficial outcome (NNTB) of 12 (95% CI 7 to 128), i.e. providing OHC including CHX for 12 ventilated patients in intensive care would prevent one patient developing VAP. There was no evidence of a difference between interventions for the outcomes of mortality (RR 1.03, 95% CI 0.80 to 1.33; P = 0.86, I2 = 0%; 9 RCTs, 944 participants; moderate-certainty evidence), duration of mechanical ventilation (MD -1.10 days, 95% CI -3.20 to 1.00 days; P = 0.30, I2 = 74%; 4 RCTs, 594 participants; very low-certainty evidence) or duration of intensive care unit (ICU) stay (MD -0.89 days, 95% CI -3.59 to 1.82 days; P = 0.52, I2 = 69%; 5 RCTs, 627 participants; low-certainty evidence). Most studies did not mention adverse effects. One study reported adverse effects, which were mild, with similar frequency in CHX and control groups and one study reported there were no adverse effects. Toothbrushing (± antiseptics) may reduce the incidence of VAP (RR 0.61, 95% CI 0.41 to 0.91; P = 0.01, I2 = 40%; 5 RCTs, 910 participants; low-certainty evidence) compared to OHC without toothbrushing (± antiseptics). There is also some evidence that toothbrushing may reduce the duration of ICU stay (MD -1.89 days, 95% CI -3.52 to -0.27 days; P = 0.02, I2 = 0%; 3 RCTs, 749 participants), but this is very low certainty. Low-certainty evidence did not show a reduction in mortality (RR 0.84, 95% CI 0.67 to 1.05; P = 0.12, I2 = 0%; 5 RCTs, 910 participants) or duration of mechanical ventilation (MD -0.43, 95% CI -1.17 to 0.30; P = 0.25, I2 = 46%; 4 RCTs, 810 participants). AUTHORS' CONCLUSIONS Chlorhexidine mouthwash or gel, as part of OHC, probably reduces the incidence of developing ventilator-associated pneumonia (VAP) in critically ill patients from 26% to about 18%, when compared to placebo or usual care. We did not find a difference in mortality, duration of mechanical ventilation or duration of stay in the intensive care unit, although the evidence was low certainty. OHC including both antiseptics and toothbrushing may be more effective than OHC with antiseptics alone to reduce the incidence of VAP and the length of ICU stay, but, again, the evidence is low certainty. There is insufficient evidence to determine whether any of the interventions evaluated in the studies are associated with adverse effects.
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Affiliation(s)
- Tingting Zhao
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Xinyu Wu
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Qi Zhang
- Department of Oral Implantology, The Affiliated Stomatology Hospital, Zhejiang University School of Medicine, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Hangzhou, China
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Helen V Worthington
- Cochrane Oral Health, Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Fang Hua
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Centre for Evidence-Based Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
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Shahdad S, Patel T, Hindocha A, Cagney N, Mueller JD, Seoudi N, Morgan C, Din A. The efficacy of an extraoral scavenging device on reduction of splatter contamination during dental aerosol generating procedures: an exploratory study. Br Dent J 2020:10.1038/s41415-020-2112-7. [PMID: 32918060 PMCID: PMC7484927 DOI: 10.1038/s41415-020-2112-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 08/07/2020] [Indexed: 01/04/2023]
Abstract
Introduction This study was conducted in light of the SARS-CoV-2 pandemic, which brought UK dentistry to a standstill. The market has seen a recent influx of unproven extraoral scavengers (EOSs), which claim to reduce the risk of particulate spread.Aims To investigate the efficacy of a commercially available EOS device on contamination reduction during dental aerosol generating procedures (AGPs). The secondary aim was to investigate differences between open and closed dental operatories.Method Dental procedures were simulated on a dental manikin using citric acid (10%) added to the water lines with universal indicating paper (UIP) placed in strategic locations in the operatory, on the clinician and assistant. Chromatic change related to settling of splatter containing citric acid on the UIP was analysed to calculate percentage intensity of splatter contamination.Results EOSs resulted in 20% reduction in frequency and 75% reduction in mean intensity of contamination of operatory sites. There was a 33% and 76% reduction in mean intensity contamination for clinician and assistant, respectively. Use of rubber dam and four-handed dentistry resulted in further reduction.Discussion This exploratory study demonstrates contamination by splatter in a simulated dental setting. The concern in dentistry regarding aerosol requires further quantitative investigation of smaller particles.Conclusions The routine use of four-handed dentistry and rubber dam should continue where possible to maximise risk mitigation during AGPs. However, on the basis of our findings, the use of an EOS device can further mitigate the magnitude and concentration of splatter.
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Affiliation(s)
- Shakeel Shahdad
- Honorary Clinical Professor in Oral Rehabilitation & Implantology and Consultant in Restorative Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Barts Health NHS Trust, The Royal London Dental Hospital, London, UK.
| | - Tulsi Patel
- Dental Core Trainee, Restorative Dentistry and General Duties, Barts Health NHS Trust, The Royal London Dental Hospital, London, UK
| | - Annika Hindocha
- Dental Core Trainee, Restorative Dentistry and General Duties, Barts Health NHS Trust, The Royal London Dental Hospital, London, UK
| | - Neil Cagney
- Lecturer School of Engineering and Materials Science, Queen Mary University of London, Mile End Road, London, E1 4NS, UK
| | - Jens-Dominik Mueller
- Reader in Computational Fluid Dynamics and Optimisation, School of Engineering and Materials Science, Queen Mary University of London, Mile End Road, London, E1 4NS, UK
| | - Noha Seoudi
- Senior Clinical Lecturer in Oral Microbiology, Centre for Oral Immunobiology and Regenerative Medicine; Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AD, UK
| | - Claire Morgan
- Consultant in Restorative Dentistry, Barts Health NHS Trust, The Royal London Dental Hospital, London, UK
| | - Ahmed Din
- Post-CCST Speciality Registrar in Orthodontics, Barts Health NHS Trust, The Royal London Dental Hospital, London, UK
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20
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Files DC, Heinrich T, Shields KL, Love NJ, Brailer C, Bakhru RN, Purcell L, Flores L, Gibbs K, Miller GD, Morris PE, Berry MJ. A randomized pilot study of nitrate supplementation with beetroot juice in acute respiratory failure. Nitric Oxide 2019; 94:63-68. [PMID: 31669503 DOI: 10.1016/j.niox.2019.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/01/2019] [Accepted: 10/24/2019] [Indexed: 02/04/2023]
Abstract
Nitrate rich beetroot juice (BRJ) can enhance nitric oxide signaling, leading to improved physical function in healthy and diseased populations, but its safety and biologic efficacy have not been evaluated in a critically ill population. We randomized 22 previously functional acute respiratory failure patients to either BRJ or placebo daily until day 14 or discharge. We measured blood nitrate and nitrite levels and quantified strength and physical function at intensive care unit (ICU) and hospital discharge. Participants were predominantly male (54%), aged 68.5 years with an APACHE III score of 62. BRJ increased plasma nitrate (mean 219.2 μM increase, p = 0.002) and nitrite levels (mean 0.144 μM increase, p = 0.02). We identified no adverse events. The unadjusted and adjusted effect sizes of the intervention on the short physical performance battery were small (d = 0.12 and d = 0.17, respectively). In this pilot trial, administration of BRJ was feasible and safe, increased blood nitrate and nitrate levels, but had a small effect on physical function. Future studies could evaluate the clinical efficacy of BRJ as a therapy to improve physical function in survivors of critical illness.
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Affiliation(s)
- D Clark Files
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA; Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | - Timothy Heinrich
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Katherine L Shields
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Nathan J Love
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Carly Brailer
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Rita N Bakhru
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA; Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Lina Purcell
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Lori Flores
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Kevin Gibbs
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA; Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Gary D Miller
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Peter E Morris
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, USA
| | - Michael J Berry
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
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Dale CM, Rose L, Carbone S, Smith OM, Burry L, Fan E, Amaral ACKB, McCredie VA, Pinto R, Quiñonez CR, Sutherland S, Scales DC, Cuthbertson BH. Protocol for a multi-centered, stepped wedge, cluster randomized controlled trial of the de-adoption of oral chlorhexidine prophylaxis and implementation of an oral care bundle for mechanically ventilated critically ill patients: the CHORAL study. Trials 2019; 20:603. [PMID: 31651364 PMCID: PMC6814100 DOI: 10.1186/s13063-019-3673-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/21/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Routine application of chlorhexidine oral rinse is recommended to reduce risk of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Recent reappraisal of the evidence from two meta-analyses suggests chlorhexidine may cause excess mortality in non-cardiac surgery patients and does not reduce VAP. Mechanisms for possible excess mortality are unclear. The CHORAL study will evaluate the impact of de-adopting chlorhexidine and implementing an oral care bundle (excluding chlorhexidine) on mortality, infection-related ventilator-associated complications (IVACs), and oral health status. METHODS The CHORAL study is a stepped wedge, cluster randomized controlled trial in six academic intensive care units (ICUs) in Toronto, Canada. Clusters (ICU) will be randomly allocated to six sequential steps over a 14-month period to de-adopt oral chlorhexidine and implement a standardized oral care bundle (oral assessment, tooth brushing, moisturization, and secretion removal). On study commencement, all clusters begin with a control period in which the standard of care is oral chlorhexidine. Clusters then begin crossover from control to intervention every 2 months according to the randomization schedule. Participants include all mechanically ventilated adults eligible to receive the standardized oral care bundle. The primary outcome is ICU mortality; secondary outcomes are IVACs and oral health status. We will determine demographics, antibiotic usage, mortality, and IVAC rates from a validated local ICU clinical registry. With six clusters and 50 ventilated patients on average each month per cluster, we estimate that 4200 patients provide 80% power after accounting for intracluster correlation to detect an absolute reduction in mortality of 5.5%. We will analyze our primary outcome of mortality using a generalized linear mixed model adjusting for time to account for secular trends. We will conduct a process evaluation to determine intervention fidelity and to inform interpretation of the trial results. DISCUSSION The CHORAL study will inform understanding of the effectiveness of de-adoption of oral chlorhexidine and implementation of a standardized oral care bundle for decreasing ICU mortality and IVAC rates while improving oral health status. Our process evaluation will inform clinicians and decision makers about intervention delivery to support future de-adoption if justified by trial results. TRIAL REGISTRATION ClinicalTrials.gov, NCT03382730 . Registered on December 26, 2017.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada.,Sunnybrook Research Institute, Toronto, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, UK
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Orla M Smith
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Department of Critical Care, St. Michael's Hospital, Toronto, Canada.,Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Lisa Burry
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Susan Sutherland
- Department of Dentistry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Brian H Cuthbertson
- Sunnybrook Research Institute, Toronto, Canada. .,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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Jackson L, Owens M. Does oral care with chlorhexidine reduce ventilator-associated pneumonia in mechanically ventilated adults? ACTA ACUST UNITED AC 2019; 28:682-689. [PMID: 31188655 DOI: 10.12968/bjon.2019.28.11.682] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Oral colonisation by pathogens contributes to contracting ventilator-associated pneumonia (VAP). The aim of this review was to determine whether the use of the antiseptic chlorhexidine in the intra-oral cavity reduced its incidence in the critically ill, mechanically ventilated adult. The findings from this review led to the conclusion that chlorhexidine reduced the occurrence of VAP. Although a recommendation to implement the use of intra-oral chlorhexidine for mechanically-ventilated patients within critical care can be made, further exploration into required frequency and method of administration would be beneficial to reduce unnecessary exposure and hinder pathogenic resistance.
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Affiliation(s)
- Laura Jackson
- Nursing Sister, Neurosurgical Critical Care Ward L06/L07, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds
| | - Melissa Owens
- Lecturer, School of Nursing and Healthcare Leadership, Faculty of Health Studies, University of Bradford
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de Camargo L, da Silva SN, Chambrone L. Efficacy of toothbrushing procedures performed in intensive care units in reducing the risk of ventilator-associated pneumonia: A systematic review. J Periodontal Res 2019; 54:601-611. [PMID: 31206663 DOI: 10.1111/jre.12668] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/15/2019] [Accepted: 05/01/2019] [Indexed: 11/28/2022]
Abstract
The aim of this systematic review (SR) was to assess whether toothbrushing-based oral heath measure (OHM), performed in intensive care units, can reduce the risk of ventilator-associated pneumonia (VAP). Dental biofilm removal has been considered important to prevent VAP. PUBMED, SCOPUS, WEB OF SCIENCE and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched up to and including December 2018 to identify randomized clinical trials (RCT) on the use of toothbrushing procedures in the prevention of VAP. Search was conducted by two independent reviewers. The risk of bias of each included study was assessed using the Cochrane Collaboration's domain-based, two-part tool. Random effects meta-analyses were conducted thoroughly. Search strategy identified 215 potentially eligible articles, of which 12 RCT were included. All studies evidenced the importance of OHM in mechanically ventilated patients in order to prevent VAP. Seven RCT (58.3%) found some degree of positive association between toothbrushing, alone or associated to oral topical chlorhexidine (CHX), and a potential reduction of mechanical ventilation-related outcomes and dental biofilm/oral bacteria. However, pooled estimates did not identify an additional decrease of VAP incidence for any of the tested procedures (ie, toothbrushing + CHX versus swab/gauze cleaning + CHX or toothbrushing + CHX versus toothbrushing alone or + placebo). Toothbrushing does not seem to promote a reduction of VAP-outcomes compared to swab/gauze cleaning, when topic CHX is applied for oral hygiene of patients submitted to mechanical ventilation.
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Affiliation(s)
- Luiz de Camargo
- MSc Dentistry Program, Ibirapuera University (Unib), São Paulo, Brazil
| | | | - Leandro Chambrone
- MSc Dentistry Program, Ibirapuera University (Unib), São Paulo, Brazil.,Unit of Basic Oral Investigation (UIBO), School of Dentistry, El Bosque University, Bogota, Colombia
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24
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Zou L, Vexler A, Yu J, Wan H. A sequential density-based empirical likelihood ratio test for treatment effects. Stat Med 2019; 38:2115-2125. [PMID: 30663088 DOI: 10.1002/sim.8095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 12/06/2018] [Accepted: 12/20/2018] [Indexed: 11/07/2022]
Abstract
In health-related experiments, treatment effects can be identified using paired data that consist of pre- and posttreatment measurements. In this framework, sequential testing strategies are widely accepted statistical tools in practice. Since performances of parametric sequential testing procedures vitally depend on the validity of the parametric assumptions regarding underlying data distributions, we focus on distribution-free mechanisms for sequentially evaluating treatment effects. In fixed sample size designs, the density-based empirical likelihood (DBEL) methods provide powerful nonparametric approximations to optimal Neyman-Pearson-type statistics. In this article, we extend the DBEL methodology to develop a novel sequential DBEL testing procedure for detecting treatment effects based on paired data. The asymptotic consistency of the proposed test is shown. An extensive Monte Carlo study confirms that the proposed test outperforms the conventional sequential Wilcoxon signed-rank test across a variety of alternatives. The excellent applicability of the proposed method is exemplified using the ventilator-associated pneumonia study that evaluates the effect of Chlorhexidine Gluconate treatment in reducing oral colonization by pathogens in ventilated patients.
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Affiliation(s)
- Li Zou
- Department of Statistics and Biostatistics, California State University, East Bay, Hayward, California
| | - Albert Vexler
- Department of Biostatistics, The State University of New York at Buffalo, Buffalo, New York
| | - Jihnhee Yu
- Department of Biostatistics, The State University of New York at Buffalo, Buffalo, New York
| | - Hongzhi Wan
- Department of Biostatistics, The State University of New York at Buffalo, Buffalo, New York
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25
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Khasanah IH, Sae-Sia W, Damkliang J. The Effectiveness of Oral Care Guideline Implementation on Oral Health Status in Critically Ill Patients. SAGE Open Nurs 2019; 5:2377960819850975. [PMID: 33415244 PMCID: PMC7774391 DOI: 10.1177/2377960819850975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 04/01/2019] [Accepted: 04/20/2019] [Indexed: 11/29/2022] Open
Abstract
Intubated patients need specific oral care due to the use of endotracheal tubes. An oral nursing care guideline needs to be implemented to guide nurses in oral care in intubated patients. To test the effectiveness of oral nursing care guideline implementation. The Rogers' Diffusion of Innovations Theory was used to introduce an oral nursing care guideline to 28 nurses working in an intensive care unit in a hospital within 2 months, using mass and private communication within a hospital management system. The oral care guideline was introduced to 47 intubated patients. The accuracy of oral care practice was assessed by nurse research assistants, and patients' oral health status was examined by dental nurse research assistants. The accuracy of practice among nurses was found between 88% and 100%. Total 97.47% (n = 46) of patients had an acceptable oral health status after receiving oral care based on the oral nursing care guideline. The oral nursing care guideline was effectively implemented with high accuracy and could increase patient oral integrity after its implementation.
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Affiliation(s)
| | - Wipa Sae-Sia
- Faculty of Nursing, Prince of Songkla University, Thailand
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26
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Manzano BR, Santaella NG, Oliveira MA, Rubira CMF, Santos PSDS. Retrospective study of osteoradionecrosis in the jaws of patients with head and neck cancer. J Korean Assoc Oral Maxillofac Surg 2019; 45:21-28. [PMID: 30847293 PMCID: PMC6400702 DOI: 10.5125/jkaoms.2019.45.1.21] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/05/2018] [Accepted: 06/08/2018] [Indexed: 01/20/2023] Open
Abstract
Objectives Osteoradionecrosis (ORN) is one of the most severe complications resulting from radiotherapy (RT) in patients with head and neck cancer (HNC). It is characterized by persistent exposed and devitalized bone without proper healing for greater than 6 months after a high dose of radiation in the area. To describe the profile and dental management of ORN in HNC patients undergoing RT in an oncological clinical research center. Materials and Methods A retrospective descriptive study was performed to analyze dental records from HNC patients with ORN treated at an oncological clinical research center from 2013 to 2017. A total of 158 dental records for HNC patients were selected from a total of 583 records. Afterwards, this number was distributed to three examiners for manual assessments. Each examiner was responsible for selecting dental records that contained an ORN description, resulting in 20 dental records. Results Mean patient age was 60.3 years with males being the most affected sex (80.0%). The most affected area was the posterior region of the mandible (60.0%) followed by the anterior region of the mandible (20.0%) and the posterior region of the maxilla (10.0%). The factors most associated with ORN were dental conditions (70.0%) followed by isolated systemic factors (10.0%) and tumor resection (5.0%). There was total exposed bone closure in 50.0% of cases. The predominant treatment was curettage associated with chlorhexidine 0.12% irrigation (36.0%). Conclusion Poor dental conditions were related to ORN occurrence. ORN management through less invasive therapies was effective for the closure of exposed bone areas and avoidance of infection.
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Affiliation(s)
- Brena Rodrigues Manzano
- Departament of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | - Natália Garcia Santaella
- Departament of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | - Marco Aurélio Oliveira
- Departament of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | - Cássia Maria Fischer Rubira
- Departament of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | - Paulo Sérgio da Silva Santos
- Departament of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
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27
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Sabetian G, Nikandish R, Zand F, Faghihi H, Masjedi M, Maghsoudi B, Vazin A, Ghorbani M, Asadpour E. Comparing the ventilator-associated pneumonia incidence when pantoprazole or ranitidine is used for stress ulcer prophylaxis in critically ill adult patients. INTERNATIONAL ARCHIVES OF HEALTH SCIENCES 2019. [DOI: 10.4103/iahs.iahs_16_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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28
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Dai R, Lam OLT, Lo ECM, Li LSW, McGrath C. Effect of oral hygiene programmes on oral opportunistic pathogens during stroke rehabilitation. Oral Dis 2018; 25:617-633. [PMID: 30447165 DOI: 10.1111/odi.13005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 10/28/2018] [Accepted: 11/11/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVES This study was to assess the effectiveness of a conventional oral hygiene care programme (COHCP) and an advanced oral hygiene care programme (AOHCP) on prevalence and viable counts of oral opportunistic pathogens among patients undergoing stroke rehabilitation. METHODS A total of 94 patients were randomized to two groups. Subjects were block randomized to either (a) COHCP: manual toothbrushing with oral hygiene instruction (OHI); or (b) AOHCP: powered toothbrushing, mouthrinsing with chlorhexidine and OHI. Prevalence and viable counts of oral opportunistic pathogens including yeasts, aerobic and facultative anaerobic gram-negative bacilli, Staphylococcus aureus, were assessed at baseline, the end of 3 and 6 months. RESULTS No significant difference was observed in the prevalence of oral opportunistic pathogens within each group over the clinical trial period. A significant decrease in the viable counts of S. aureus was found over the clinical trial period within AOHCP group (p < 0.05), while the viable counts of yeasts and anaerobic gram-negative bacillus (AGNB) remained stable within each group. Regression analysis failed to detect an association between intervention and the prevalence/viable counts of oral opportunistic pathogens. CONCLUSIONS Neither oral healthcare programme significantly affects AGNB, yeast or S. aureus over the study period in terms of prevalence and viable counts.
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Affiliation(s)
- Ruoxi Dai
- Dental Public Health, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong.,Key Laboratory of Oral Diseases Research of Anhui Province, Stomatologic Hospital & College, Anhui Medical University, Hefei, China
| | - Otto L T Lam
- Prosthodontics, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong
| | - Edward C M Lo
- Dental Public Health, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong
| | - Leonard S W Li
- Rehabilitation Medicine, Tung Wah Hospital, Hong Kong, Hong Kong
| | - Colman McGrath
- Dental Public Health, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong
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Meidani M, Khorvash F, Abbasi S, Cheshmavar M, Tavakoli H. Oropharyngeal Irrigation to Prevent Ventilator-Associated-Pneumonia: Comparing Potassium Permangenate with Chlorhexidine. Int J Prev Med 2018; 9:93. [PMID: 30450176 PMCID: PMC6202778 DOI: 10.4103/ijpvm.ijpvm_370_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 11/21/2017] [Indexed: 11/13/2022] Open
Abstract
Background: Pneumonia is one of the most common hospital-acquired infections among bedridden patients in Intensive Care Units (ICUs). Colonization of mouth and pharynx by pathogenic bacteria and their aspiration into the lower respiratory tract is an important step in pathogenesis of hospital-acquired pneumonia. The purpose of this study was to compare the effects of chlorhexidine and potassium permanganate mouthwashes in preventing incidence of hospital-acquired pneumonia in hospitalized patients in the ICU. Methods: This study is a clinical trial, conducted on 150 patients on ventilator in ICU. Patients were divided into three groups: Chlorhexidine group, potassium permanganate group, and control group. Mouthwashing three times a day, each time 5 min for 1 week by sterile gas with 10 cc solution of chlorhexidine, potassium permanganate, or placebo, was performed. Finally, pneumonia incidence was recorded, according to the Center for Disease Control and Prevention criteria. The data were analyzed by SPSS software version 20. Results: In the present study, 28 cases of pneumonia among 150 patients on ventilator were investigated. There were 15 (30%), 6 (12%), and 7 (14%) incidences of pneumonia in control, chlorhexidine, and permanganate group, respectively. Pneumonia incidence in these groups differed significantly (P = 0.041). Conclusions: The use of common mouthwashes, especially chlorhexidine solution, for washing oropharynx of ICU patients, can decrease pneumonia incidence, especially in patients under ventilation. Thus, washing and sterilizing mouth of patients with mouthwashes is recommended due to the high risk of hospital-acquired pneumonia in these patients.
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Affiliation(s)
- Mohsen Meidani
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.,Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzin Khorvash
- Nosocomial Infection Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Abbasi
- Department of Anesthesiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoumeh Cheshmavar
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Tavakoli
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.,Department of Biology, University of British Columbia, Kelowna, Canada
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30
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Ab Malik N, Abdul Razak F, Mohamad Yatim S, Lam OLT, Jin L, Li LS, McGrath C. Oral Health Interventions Using Chlorhexidine—Effects on the Prevalence of Oral Opportunistic Pathogens in Stroke Survivors: A Randomized Clinical Trial. J Evid Based Dent Pract 2018; 18:99-109. [DOI: 10.1016/j.jebdp.2017.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 01/22/2023]
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31
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Scannapieco FA, Cantos A. Oral inflammation and infection, and chronic medical diseases: implications for the elderly. Periodontol 2000 2018; 72:153-75. [PMID: 27501498 DOI: 10.1111/prd.12129] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2015] [Indexed: 12/12/2022]
Abstract
Oral diseases, such as caries and periodontitis, not only have local effects on the dentition and on tooth-supporting tissues but also may impact a number of systemic conditions. Emerging evidence suggests that poor oral health influences the initiation and/or progression of diseases such as atherosclerosis (with sequelae including myocardial infarction and stoke), diabetes mellitus and neurodegenerative diseases (such as Alzheimer's disease, rheumatoid arthritis and others). Aspiration of oropharyngeal (including periodontal) bacteria causes pneumonia, especially in hospitalized patients and the elderly, and may influence the course of chronic obstructive pulmonary disease. This article addresses several pertinent aspects related to the medical implications of periodontal disease in the elderly. There is moderate evidence that improved oral hygiene may help prevent aspiration pneumonia in high-risk patients. For other medical conditions, because of the absence of well-designed randomized clinical trials in elderly patients, no specific guidance can be provided regarding oral hygiene or periodontal interventions that enhance the medical management of older adults.
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Martín A, Ortega O, Roca M, Arús M, Clavé P. Effect of A Minimal-Massive Intervention in Hospitalized Older Patients with Oropharyngeal Dysphagia: A Proof of Concept Study. J Nutr Health Aging 2018; 22:739-747. [PMID: 29806864 DOI: 10.1007/s12603-018-1043-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Oropharyngeal dysphagia (OD) is a newly defined geriatric syndrome that causes nutritional and respiratory complications in older hospitalized patients. Following hospital discharge, OD also causes hospital readmission and mortality in this population. OBJECTIVE Our aim was to assess the effect of a minimal-massive intervention (MMI) in reducing nutritional and respiratory complications in older hospitalized patients with OD. DESIGN AND PARTICIPANTS An open label trial was performed on 186 hospitalized older patients (>70y) with OD; 62 of these patients with OD were treated with the MMI and paired by sex, age, functionality, comorbidities and body mass index with two controls. INTERVENTION The MMI consisted of: a) fluid thickening and texture-modified foods, b) caloric and protein supplementation; and c) oral health and hygiene recommendations during hospitalization and following discharge. The control group followed the standard clinical practice without MMI. MEASUREMENTS Main study outcomes were hospital readmissions, respiratory infections, nutritional status and survival after 6 months follow up. RESULTS Both groups had similar advanced age (84.87±6.02MMI and 84.42±5.31 years), poor functionality (Barthel 59.51±26.76 MMI and 58.84±26.87), and high comorbidities (Charlson 3.00±1.60 MMI and 3.06±1.45). Main results showed that MMI improved nutritional status (MNA 9.84±2.05 pre-MMI vs. 11.31±2.21 post-MMI; p=0.0038) and functionality (Barthel 62.34±25.43 pre-MMI vs. 73.44±25.19 post-MMI; p=0.007). In addition MMI decreased hospital readmissions (68.8 readmissions/100 persons-year (28.1-109.38) MMI vs. 190.8 (156.0-225.7); p=0.001), respiratory infections (12.50 readmissions/100 persons-year (0-29.82) MMI vs. 74.68 (52.86-96.50); p=0.002), and increased 6-month survival (84.13% MMI vs. 70.96%; p=0.044). CONCLUSIONS Our results suggest that a MMI in hospitalized older patients with OD improves nutritional status and functionality and reduces hospital readmissions, respiratory infections and mortality. MMI might become a new simple and cost-effective strategy to avoid OD complications in the geriatric population admitted with an acute disease to a general hospital.
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Affiliation(s)
- A Martín
- Pere Clavé Civit, MD, PhD Surgeon. Principal Investigator. Associate Professor of Surgery Universitat Autònoma de Barcelona. +34 937417700 ext. 1046. Fax: +34 937417733. e-mail:
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Fernandes KS, Lima MB, Martins CDP, Dos-Santos MC, Nunes FD, Kokron CM, Gallottini M. Salivary Immunoglobulins in Individuals with Common Variable Immunodeficiency. Braz Dent J 2017; 27:641-645. [PMID: 27982172 DOI: 10.1590/0103-6440201601096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/13/2016] [Indexed: 11/22/2022] Open
Abstract
Oral manifestations of common variable immunodeficiency (CVID) are rare, have rarely been studied and have given controversial results. There are few data about IgA, IgG, and IgM antibody salivary levels in the literature, and there are few papers about the clinical impact of antibody deficiencies and CVID on the oral health of such patients. The aim of this study was to measure serum and salivary IgA, IgG, and IgM levels in CVID participants and controls, and to associate immunoglobulin levels with caries and periodontal disease. This was a case-control study involving 51 CVID individuals and 50 healthy controls. All participants underwent examination for dental caries and periodontal disease. Blood and whole saliva samples were collected on the same day of the oral examination. Serum IgA, IgM, and IgG levels were measured by turbidimetry and salivary IgA, IgM, and IgG titers were assessed by enzyme-linked immunosorbent assay. Incidences of caries and gingivitis were significantly higher in the CVID group than in the control group (p<0.05). Salivary and blood IgA and IgM titers were significantly reduced in the CVID group, but there was no association of salivary immunoglobulin levels with periodontal disease or with caries incidence (p>0.05 for both). Although CVID was associated with increased susceptibility to caries and gingivitis, it was not associated with low salivary levels of IgA and IgM.
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Affiliation(s)
- Karin Sá Fernandes
- Stomatology Department, Dental School of São Paulo, USP - Universidade de São Paulo, SP, Brazil
| | - Michella Bezerra Lima
- Stomatology Department, Dental School of São Paulo, USP - Universidade de São Paulo, SP, Brazil
| | - Cíntia de Paula Martins
- Stomatology Department, Dental School of São Paulo, USP - Universidade de São Paulo, SP, Brazil
| | - Maria Cristina Dos-Santos
- Department of Parasitology, Institute of Biological Sciences, UFAM - Universidade Federal do Amazonas, Manaus, AM, Brazil
| | - Fabio Daumas Nunes
- Stomatology Department, Dental School of São Paulo, USP - Universidade de São Paulo, SP, Brazil
| | - Cristina Maria Kokron
- Laboratory of Clinical Immunology and Allergy, LIM-60, Hospital das Clínicas, USP - Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marina Gallottini
- Stomatology Department, Dental School of São Paulo, USP - Universidade de São Paulo, SP, Brazil
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Abstract
Bayes factors, practical tools of applied statistics, have been dealt with extensively in the literature in the context of hypothesis testing. The Bayes factor based on parametric likelihoods can be considered both as a pure Bayesian approach as well as a standard technique to compute p-values for hypothesis testing. We employ empirical likelihood methodology to modify Bayes factor type procedures for the nonparametric setting. The paper establishes asymptotic approximations to the proposed procedures. These approximations are shown to be similar to those of the classical parametric Bayes factor approach. The proposed approach is applied towards developing testing methods involving quantiles, which are commonly used to characterize distributions. We present and evaluate one and two sample distribution free Bayes factor type methods for testing quantiles based on indicators and smooth kernel functions. An extensive Monte Carlo study and real data examples show that the developed procedures have excellent operating characteristics for one-sample and two-sample data analysis.
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Affiliation(s)
- Albert Vexler
- Department of Biostatistics, The State University of New York, Buffalo, NY 14214, USA
| | - Jihnhee Yu
- Department of Biostatistics, The State University of New York, Buffalo, NY 14214, USA
| | - Nicol Lazar
- Department of Statistics, University of Georgia, Athens, GA 30602-7952, USA
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Zand F, Zahed L, Mansouri P, Dehghanrad F, Bahrani M, Ghorbani M. The effects of oral rinse with 0.2% and 2% chlorhexidine on oropharyngeal colonization and ventilator associated pneumonia in adults' intensive care units. J Crit Care 2017; 40:318-322. [PMID: 28320561 DOI: 10.1016/j.jcrc.2017.02.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/08/2017] [Accepted: 02/19/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ventilator Associated Pneumonia (VAP) is the most common nosocomial infection in Intensive Care Units (ICUs) which increases the length of ICU stay, duration of mechanical ventilation, and mortality. The present study used an oral care protocol and compared the effects of two different concentrations of chlorhexidine on reduction of oropharyngeal colonization and VAP. MATERIALS AND METHODS This study was performed on 114 patients from trauma, surgery, neurosurgery, and general ICUs randomly allocated to two groups under oral care with 0.2% and 2% chlorhexidine solution. A multidisciplinary team approved the oral care protocol. Data was collected using a demographic information form, APACHE IV form, Beck oral assessment scale, mucosal-plaque assessment scale, and oropharyngeal swab culture. RESULTS The results showed a significant reduction in VAP (p=0.007) and oropharyngeal colonization (p=0.007) in the group under oral care with 2% chlorhexidine solution compared with the other group. However, no significant difference was found between the two groups in terms of oropharyngeal adverse effects (p=0.361). CONCLUSION Oral decontamination with 2% compared to 0.2% chlorhexidine is a more effective method in the prevention of VAP and reduction of oropharyngeal colonization (especially gram-positive).
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Affiliation(s)
- Farid Zand
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leili Zahed
- Fatemeh Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parisa Mansouri
- Fatemeh Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Freshte Dehghanrad
- Fatemeh Nursing and Midwifery School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Bahrani
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Ghorbani
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Risk factors for ventilator-associated pneumonia: among trauma patients with and without brain injury. J Trauma Nurs 2016; 22:125-31. [PMID: 25961478 DOI: 10.1097/jtn.0000000000000121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Ventilator-associated pneumonia (VAP) rates remain highest among trauma and brain injured patients; yet, no research compares VAP risk factors between the 2 groups. This retrospective, case-controlled study identified risk factors for VAP among critically ill trauma patients with and without brain injury. Data were abstracted on trauma patients with (cases) and without (controls) brain injury. Data gathered on n = 157 subjects. Trauma patients with brain injury had more emergent and field intubations. Age was strongest predictor of VAP in cases, and ventilator days predicted VAP in controls. Trauma patients with brain injury may be at higher risk for VAP.
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Baijens LW, Clavé P, Cras P, Ekberg O, Forster A, Kolb GF, Leners JC, Masiero S, Mateos-Nozal J, Ortega O, Smithard DG, Speyer R, Walshe M. European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome. Clin Interv Aging 2016. [PMID: 27785002 DOI: 10.2147/cia.s107750.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.
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Affiliation(s)
- Laura Wj Baijens
- Department of Otorhinolaryngology - Head and Neck Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital of Mataró, Autonomous University of Barcelona, Mataró; CIBERehd, Instituto de Salud Carlos III, Barcelona, Spain
| | - Patrick Cras
- Department of Neurology, Antwerp University Hospital, University of Antwerp, Born Bunge Institute, Edegem, Belgium
| | - Olle Ekberg
- Department of Translational Medicine, Division of Medical Radiology, Skåne University Hospital, Malmö, Sweden
| | | | - Gerald F Kolb
- Department of Geriatrics and Physical Medicine, Bonifatius Hospital, Lingen, Germany
| | | | - Stefano Masiero
- Rehabilitation Unit, Department of Neuroscience, University of Padua, Padova, Italy
| | | | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital of Mataró, Autonomous University of Barcelona, Mataró; CIBERehd, Instituto de Salud Carlos III, Barcelona, Spain
| | - David G Smithard
- Clinical Gerontology, Princess Royal University Hospital, King's College Hospital Foundation Trust, London, UK
| | - Renée Speyer
- College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
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Hua F, Xie H, Worthington HV, Furness S, Zhang Q, Li C. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev 2016; 10:CD008367. [PMID: 27778318 PMCID: PMC6460950 DOI: 10.1002/14651858.cd008367.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in people who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions, may reduce the risk of VAP in these patients. OBJECTIVES To assess the effects of oral hygiene care on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs). SEARCH METHODS We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 17 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 11), MEDLINE Ovid (1946 to 17 December 2015), Embase Ovid (1980 to 17 December 2015), LILACS BIREME Virtual Health Library (1982 to 17 December 2015), CINAHL EBSCO (1937 to 17 December 2016), Chinese Biomedical Literature Database (1978 to 14 January 2013), China National Knowledge Infrastructure (1994 to 14 January 2013), Wan Fang Database (January 1984 to 14 January 2013) and VIP Database (January 2012 to 4 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 17 December 2015. We placed no restrictions on the language or date of publication when searching the electronic databases. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed search results, extracted data and assessed risk of bias in included studies. We contacted study authors for additional information. We pooled data from trials with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, using random-effects models unless there were fewer than four studies. MAIN RESULTS We included 38 RCTs (6016 participants). There were four main comparisons: chlorhexidine (CHX) mouthrinse or gel versus placebo/usual care; toothbrushing versus no toothbrushing; powered versus manual toothbrushing; and comparisons of oral care solutions. We assessed the overall risk of bias as low in five trials (13%), high in 26 trials (68%), and unclear in seven trials (18%). We did not consider the risk of bias to be serious when assessing the quality of evidence (GRADE) for VAP incidence, but we downgraded other outcomes for risk of bias.High quality evidence from 18 RCTs (2451 participants, 86% adults) shows that CHX mouthrinse or gel, as part of OHC, reduces the risk of VAP compared to placebo or usual care from 25% to about 19% (RR 0.74, 95% confidence intervals (CI) 0.61 to 0.89, P = 0.002, I2 = 31%). This is equivalent to a number needed to treat for an additional beneficial outcome (NNTB) of 17 (95% CI 10 to 33), which indicates that for every 17 ventilated patients in intensive care receiving OHC including chlorhexidine, one outcome of VAP would be prevented. There is no evidence of a difference between CHX and placebo/usual care for the outcomes of mortality (RR 1.09, 95% CI 0.96 to 1.23, P = 0.18, I2 = 0%, 15 RCTs, 2163 participants, moderate quality evidence), duration of mechanical ventilation (MD -0.09 days, 95% CI -1.73 to 1.55 days, P = 0.91, I2 = 36%, five RCTs, 800 participants, low quality evidence), or duration of intensive care unit (ICU) stay (MD 0.21 days, 95% CI -1.48 to 1.89 days, P = 0.81, I2 = 9%, six RCTs, 833 participants, moderate quality evidence). There is insufficient evidence to determine the effect of CHX on duration of systemic antibiotics, oral health indices, caregivers' preferences or cost. Only two studies reported any adverse effects, and these were mild with similar frequency in CHX and control groups.We are uncertain as to the effects of toothbrushing (± antiseptics) on the outcomes of VAP (RR 0.69, 95% CI 0.44 to 1.09, P = 0.11, I2 = 64%, five RCTs, 889 participants, very low quality evidence) and mortality (RR 0.87, 95% CI 0.70 to 1.09, P = 0.24, I2 = 0%, five RCTs, 889 participants, low quality evidence) compared to OHC without toothbrushing (± antiseptics). There is insufficient evidence to determine whether toothbrushing affects duration of mechanical ventilation, duration of ICU stay, use of systemic antibiotics, oral health indices, adverse effects, caregivers' preferences or cost.Only one trial (78 participants) compared use of a powered toothbrush with a manual toothbrush, providing insufficient evidence to determine the effect on any of the outcomes of this review.Fifteen trials compared various other oral care solutions. There is very weak evidence that povidone iodine mouthrinse is more effective than saline/placebo (RR 0.69, 95% CI 0.50 to 0.95, P = 0.02, I2 = 74%, three studies, 356 participants, high risk of bias), and that saline rinse is more effective than saline swab (RR 0.47, 95% CI 0.37 to 0.62, P < 0.001, I2 = 84%, four studies, 488 participants, high risk of bias) in reducing VAP. Due to variation in comparisons and outcomes among trials, there is insufficient evidence concerning the effects of other oral care solutions. AUTHORS' CONCLUSIONS OHC including chlorhexidine mouthwash or gel reduces the risk of developing ventilator-associated pneumonia in critically ill patients from 25% to about 19%. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There is no evidence that OHC including both antiseptics and toothbrushing is different from OHC with antiseptics alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline/placebo, and saline rinse is more effective than saline swab in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP. There is also insufficient evidence to determine whether any of the interventions evaluated in the studies are associated with adverse effects.
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Affiliation(s)
- Fang Hua
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthOxford RoadManchesterUKM13 9PL
| | - Huixu Xie
- West China College of Stomatology, Sichuan UniversityDepartment of Oral and Maxillofacial Surgery, State Key Laboratory of Oral DiseasesNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthOxford RoadManchesterUKM13 9PL
| | - Susan Furness
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthOxford RoadManchesterUKM13 9PL
| | - Qi Zhang
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan UniversityDepartment of Oral ImplantologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
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Baijens LWJ, Clavé P, Cras P, Ekberg O, Forster A, Kolb GF, Leners JC, Masiero S, Mateos-Nozal J, Ortega O, Smithard DG, Speyer R, Walshe M. European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome. Clin Interv Aging 2016; 11:1403-1428. [PMID: 27785002 PMCID: PMC5063605 DOI: 10.2147/cia.s107750] [Citation(s) in RCA: 383] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.
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Affiliation(s)
- Laura WJ Baijens
- Department of Otorhinolaryngology – Head and Neck Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital of Mataró, Autonomous University of Barcelona, Mataró
- CIBERehd, Instituto de Salud Carlos III, Barcelona, Spain
| | - Patrick Cras
- Department of Neurology, Antwerp University Hospital, University of Antwerp, Born Bunge Institute, Edegem, Belgium
| | - Olle Ekberg
- Department of Translational Medicine, Division of Medical Radiology, Skåne University Hospital, Malmö, Sweden
| | | | - Gerald F Kolb
- Department of Geriatrics and Physical Medicine, Bonifatius Hospital, Lingen, Germany
| | | | - Stefano Masiero
- Rehabilitation Unit, Department of Neuroscience, University of Padua, Padova, Italy
| | | | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital of Mataró, Autonomous University of Barcelona, Mataró
- CIBERehd, Instituto de Salud Carlos III, Barcelona, Spain
| | - David G Smithard
- Clinical Gerontology, Princess Royal University Hospital, King’s College Hospital Foundation Trust, London, UK
| | - Renée Speyer
- College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
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Prospective observational study to compare oral topical metronidazole versus 0.2% chlorhexidine gluconate to prevent nosocomial pneumonia. Am J Infect Control 2016; 44:1116-1122. [PMID: 27317405 DOI: 10.1016/j.ajic.2016.03.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/08/2016] [Accepted: 03/08/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Nosocomial pneumonia is one of the most common health care-associated infections in intensive care units (ICUs) worldwide, attributing to high morbidity and mortality. Our study aim is to investigate the effectiveness of oral hygiene with 0.2% chlorhexidine gluconate (CHX) and 0.08% metronidazole (MDE) influencing the microbiologic epidemiology and incidence of nonintubation pneumonia (NIP) and ventilator-associated pneumonia (VAP). METHODS Patients who stayed >48 hours in the emergency ICU between 2008 and 2012 were enrolled and provided oral hygiene by swabbing with 0.08% MDE twice daily until discharge or death during the first year (period M), whereas CHX was applied during the following 3 years (period C). The incidence and microbiologic epidemiology of NIP and VAP were studied. RESULTS There were 873 patients enrolled. There were 44 episodes of NIP and 25 episodes of VAP that occurred among 212 patients in period M, and 84 episodes of NIP and 49 episodes of VAP occurred among 661 patients in period C. Overall, the rate of NIP and VAP decreased year by year. Acinetobacter baumannii was the most frequently identified bacteria for NIP (22.9%) and VAP (25.3%), with an annual ascent. Few changes were observed on bacteria distribution for NIP and VAP. CONCLUSIONS Oral hygiene with CHX, having reduced the incidence of nosocomial pneumonia among critical ill patients, suggests a benefit of oral hygiene in decreasing the incidence of nosocomial pneumonia, including VAP in ICUs, but not bacterial epidemiology.
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Sands KM, Wilson MJ, Lewis MAO, Wise MP, Palmer N, Hayes AJ, Barnes RA, Williams DW. Respiratory pathogen colonization of dental plaque, the lower airways, and endotracheal tube biofilms during mechanical ventilation. J Crit Care 2016; 37:30-37. [PMID: 27621110 DOI: 10.1016/j.jcrc.2016.07.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/10/2016] [Accepted: 07/24/2016] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Kirsty M Sands
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Cardiff, Wales, UK.
| | - Melanie J Wilson
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Cardiff, Wales, UK
| | - Michael A O Lewis
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Cardiff, Wales, UK
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Nicki Palmer
- Adult Critical Care, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Anthony J Hayes
- Bioimaging Hub, School of Biosciences, Cardiff University, Cardiff, Wales, UK
| | - Rosemary A Barnes
- Cardiff Institute of Infection & Immunity, School of Medicine, Heath Park, Cardiff, Wales, UK
| | - David W Williams
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Cardiff, Wales, UK
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Jang CS, Shin YS. Effects of combination oral care on oral health, dry mouth and salivary pH of intubated patients: A randomized controlled trial. Int J Nurs Pract 2016; 22:503-511. [PMID: 27349717 DOI: 10.1111/ijn.12460] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 05/02/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
Intubated patients are at risk of oral health problems. Although a variety of oral care regimens for intubated patients have been studied, there is a lack of research on the effects of combination oral care that includes tooth brushing, chlorhexidine and cold water. This open-labelled, randomized, controlled trial aimed to evaluate the effects of combination oral care on oral health status. Participants aged 20 years and older were recruited on the first day after intubation through convenience sampling in a medical intensive care unit. Random assignment was performed using an internet randomization service. The primary outcome was oral health status. Data were collected during May and June 2013. Participants were randomized to one of two groups (23 intervention and 21 control). The final analysis included 18 patients with combination oral care and 17 in the control group. The intervention group had better oral health (effect size = 1.56), less dry mouth and higher salivary pH than the control group. Any additional burden of providing combination oral care to patients who are mechanically ventilated is worthwhile in terms of clinical outcomes.
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Affiliation(s)
- Chun Sun Jang
- Department of Nursing, Samsung Changwon Hospital, Korea
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Miquel S, Lagrafeuille R, Souweine B, Forestier C. Anti-biofilm Activity as a Health Issue. Front Microbiol 2016; 7:592. [PMID: 27199924 PMCID: PMC4845594 DOI: 10.3389/fmicb.2016.00592] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 04/11/2016] [Indexed: 12/13/2022] Open
Abstract
The formation and persistence of surface-attached microbial communities, known as biofilms, are responsible for 75% of human microbial infections (National Institutes of Health). Biofilm lifestyle confers several advantages to the pathogens, notably during the colonization process of medical devices and/or patients’ organs. In addition, sessile bacteria have a high tolerance to exogenous stress including anti-infectious agents. Biofilms are highly competitive communities and some microorganisms exhibit anti-biofilm capacities such as bacterial growth inhibition, exclusion or competition, which enable them to acquire advantages and become dominant. The deciphering and control of anti-biofilm properties represent future challenges in human infection control. The aim of this review is to compare and discuss the mechanisms of natural bacterial anti-biofilm strategies/mechanisms recently identified in pathogenic, commensal and probiotic bacteria and the main synthetic strategies used in clinical practice, particularly for catheter-related infections.
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Affiliation(s)
- Sylvie Miquel
- Laboratoire Microorganismes : Génome et Environnement - UMR, CNRS 6023, Université Clermont Auvergne Clermont-Ferrand, France
| | - Rosyne Lagrafeuille
- Laboratoire Microorganismes : Génome et Environnement - UMR, CNRS 6023, Université Clermont Auvergne Clermont-Ferrand, France
| | - Bertrand Souweine
- Laboratoire Microorganismes : Génome et Environnement - UMR, CNRS 6023, Université Clermont AuvergneClermont-Ferrand, France; Service de Réanimation Médicale Polyvalente, CHU de Clermont-Ferrand, Clermont-FerrandFrance
| | - Christiane Forestier
- Laboratoire Microorganismes : Génome et Environnement - UMR, CNRS 6023, Université Clermont Auvergne Clermont-Ferrand, France
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Enwere EN, Elofson KA, Forbes RC, Gerlach AT. Impact of chlorhexidine mouthwash prophylaxis on probable ventilator-associated pneumonia in a surgical intensive care unit. Int J Crit Illn Inj Sci 2016; 6:3-8. [PMID: 27051615 PMCID: PMC4795359 DOI: 10.4103/2229-5151.177368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Prevention of ventilator-associated pneumonia is a healthcare goal. Although data is inconsistent, some studies suggest that oral chlorhexidine may decrease rates of pneumonia in mechanically-ventilated patients. We sought to assess the rate of pneumonia in the Surgical Intensive Care Unit (SICU) pre and post implementation of routine chlorhexidine mouthwash prophylaxis. Materials and Methods: A retrospective cohort study was conducted, including patients between 1/1/2009 and 12/31/2009 who did not receive chlorhexidine mouthwash compared to patients that received prophylactic chlorhexidine mouthwash between 3/1/2010 and 2/28/2011. The primary outcome of the study was rate of probable ventilator-associated pneumonia (VAP) for the pre-chlorhexidine implementation cohort compared to post-implementation, using the 2013 Center for Disease Control definitions. Mechanically ventilated patients with respiratory cultures were screened for inclusion in the study. Secondary endpoints included duration of mechanical ventilation, in-hospital mortality, ICU and hospital length of stay. Statistical analysis was conducted by Fisher's exact test for nominal data and Mann-Whitney U test for continuous data. Results: A total of 1780 mechanically ventilated patients in the pre-chlorhexidine group and 1854 in the post-chlorhexidine group were screened for inclusion. Of the 601 mechanically ventilated patients that were further evaluated for inclusion; 158 patients (26.3%) had positive cultures and were included in the study (94 pre-group and 64 post-group). The rate of probable VAP was significantly decreased in the post-group compared to the pre-group (1.85% pre vs 0.81% post, P = 0.0082). Conclusion: Use of chlorhexidine mouthwash prophylaxis may reduce rates of probable VAP. Further study is warranted.
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Affiliation(s)
- Emmanuel N Enwere
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kathryn A Elofson
- Department of Pharmacy, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Rachel C Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony T Gerlach
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Azimi M, Jouybari L, Moghadam S, Ghaemi E, Behnampoor N, Sanagoo A, Hesam M. Antimicrobial effects of chlorhexidine, matrica drop mouthwash (chamomile extract), and normal saline on hospitalized patients with endotracheal tubes. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2016; 21:458-463. [PMID: 27904627 PMCID: PMC5114788 DOI: 10.4103/1735-9066.193390] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: The functions and use of mouthwashes are variable depending on their type. Oral care in patients with endotracheal tubes is important to prevent side effects such as pneumonia. The aim of this study was to determine the antimicrobial effects of chlorhexidine, drop of Matrica mouthwash (chamomile extract), and normal saline on hospitalized patients with endotracheal tube in an intensive care unit (ICU). Materials and Methods: In this clinical trial, 39 patients admitted to the ICU were selected by convenience sampling, were matched based on age and sex, and randomly assigned to three groups (chlorhexidine, Matrica, saline). Mouth washing was performed every 8 to 48 hours. The samples were taken at time zero (before the intervention) and 48 hours after the intervention for bacterial culture. Antibacterial activity of each mouthwash on microorganisms was measured based on the growth of Staphylococcus aureus, Pneumococcal, Enterococcus, Pseudomonas, and Escherichia coli. The obtained data were then analyzed using Chi-square and Fisher's exact tests with the Statistical Package for the Social Sciences Package version 18. Results: Chlorhexidine mouthwash was more effective in preventing colonization of bacteria in the mouth (point probability = 0.06) in comparison with chamomile and saline mouthwashes. Nevertheless, none of the tested mouthwashes were able to remove pathogens, including Staphylococcus aureus, Pseudomonas, Klebsiella, and Acinetobacter. Conclusions: 0.2% chlorhexidine mouthwash has a significant effect on the bacterial colonization rate in comparison with Matrica and normal saline mouthwashes in ICU hospitalized patients with endotracheal tube.
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Affiliation(s)
- Maryam Azimi
- Department of Nursing, School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
| | - Leila Jouybari
- Nursing Research Centre, Golestan University of Medical Sciences, Gorgan, Iran
| | - Shahram Moghadam
- Department of Anesthesiology, School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Ezatolah Ghaemi
- Department of Microbiology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Naser Behnampoor
- Department of Biostatistics, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran
| | - Akram Sanagoo
- Nursing Research Centre, Golestan University of Medical Sciences, Gorgan, Iran
| | - Moslem Hesam
- Department of Nursing, School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
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Sands KM, Twigg JA, Lewis MAO, Wise MP, Marchesi JR, Smith A, Wilson MJ, Williams DW. Microbial profiling of dental plaque from mechanically ventilated patients. J Med Microbiol 2015; 65:147-159. [PMID: 26690690 PMCID: PMC5115166 DOI: 10.1099/jmm.0.000212] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Micro-organisms isolated from the oral cavity may translocate to the lower airways during mechanical ventilation (MV) leading to ventilator-associated pneumonia (VAP). Changes within the dental plaque microbiome during MV have been documented previously, primarily using culture-based techniques. The aim of this study was to use community profiling by high throughput sequencing to comprehensively analyse suggested microbial changes within dental plaque during MV. Bacterial 16S rDNA gene sequences were obtained from 38 samples of dental plaque sampled from 13 mechanically ventilated patients and sequenced using the Illumina platform. Sequences were processed using Mothur, applying a 97 % gene similarity cut-off for bacterial species level identifications. A significant ‘microbial shift’ occurred in the microbial community of dental plaque during MV for nine out of 13 patients. Following extubation, or removal of the endotracheal tube that facilitates ventilation, sampling revealed a decrease in the relative abundance of potential respiratory pathogens and a compositional change towards a more predominantly (in terms of abundance) oral microbiota including Prevotella spp., and streptococci. The results highlight the need to better understand microbial shifts in the oral microbiome in the development of strategies to reduce VAP, and may have implications for the development of other forms of pneumonia such as community-acquired infection.
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Affiliation(s)
- Kirsty M Sands
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, UK
| | - Joshua A Twigg
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, UK
| | - Michael A O Lewis
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, UK
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Julian R Marchesi
- School of Biosciences, Main Building, Park Place, Cardiff University, Cardiff, Wales, UK.,Centre for Digestive and Gut Health, Imperial College London, London, UK
| | - Ann Smith
- School of Biosciences, Main Building, Park Place, Cardiff University, Cardiff, Wales, UK
| | - Melanie J Wilson
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, UK
| | - David W Williams
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, UK
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Yu J, Yang L, Hutson AD. What is the Proper Sample Size for Studies of Periodontal Treatment? Dent Clin North Am 2015; 59:781-97. [PMID: 26427568 DOI: 10.1016/j.cden.2015.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Small sample sizes are a common problem in biomedical research, and the periodontal literature is no exception. It is a problem leading to not only reduced statistical power but also an inappropriate statistical inference of a treatment effect. Using statistical methods with an insufficient sample size may give rise to an increased chance of falsely detecting treatment efficacy. This article provides some guidelines to cope with the small sample size problem. The authors discuss adequate sample sizes in several statistical tests and then suggest alternative statistical methods that are valid with a small sample size.
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Affiliation(s)
- Jihnhee Yu
- Department of Biostatistics, University at Buffalo, The State University of New York, 706 Kimball Tower, Buffalo, NY 14214-3000, USA.
| | - Luge Yang
- Department of Biostatistics, University at Buffalo, The State University of New York, 706 Kimball Tower, Buffalo, NY 14214-3000, USA
| | - Alan D Hutson
- Department of Biostatistics, University at Buffalo, The State University of New York, 706 Kimball Tower, Buffalo, NY 14214-3000, USA
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Abstract
BACKGROUND The use of propolis mouth rinse or gel as a supplementary intervention has increased during the last decade in Taiwan. However, the effect of propolis on oral health is not well understood. PURPOSE The purpose of this meta-analysis was to present the best available evidence regarding the effects of propolis use on oral health, including oral infection, dental plaque, and stomatitis. METHODS Researchers searched seven electronic databases for relevant articles published between 1969 and 2012. Data were collected using inclusion and exclusion criteria. The Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument was used to evaluate the quality of the identified articles. RESULTS Eight trials published from 1997 to 2011 with 194 participants had extractable data. The result of the meta-analysis indicated that, although propolis had an effect on reducing dental plaque, this effect was not statistically significant. The results were not statistically significant for oral infection or stomatitis. CONCLUSIONS/IMPLICATIONS FOR PRACTICE Although there are a number of promising indications, in view of the limited number and quality of studies and the variation in results among studies, this review highlights the need for additional well-designed trials to draw conclusions that are more robust.
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Vilela MCN, Ferreira GZ, Santos PSDS, Rezende NPMD. Oral care and nosocomial pneumonia: a systematic review. ACTA ACUST UNITED AC 2015; 13:290-6. [PMID: 25946053 PMCID: PMC4943826 DOI: 10.1590/s1679-45082015rw2980] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 07/21/2014] [Indexed: 11/21/2022]
Abstract
To perform a systematic review of the literature on the control of oral biofilms and the incidence of nosocomial pneumonia, in addition to assessing and classifying studies as to the grade of recommendation and level of evidence. The review was based on PubMed, LILACS, and Scopus databases, from January 1st, 2000 until December 31st, 2012. Studies evaluating oral hygiene care related to nosocomial infections in patients hospitalized in intensive care units were selected according to the inclusion criteria. Full published articles available in English, Spanish, or Portuguese, which approached chemical or mechanical oral hygiene techniques in preventing pneumonia, interventions performed, and their results were included. After analysis, the articles were classified according to level of evidence and grade of recommendation according to the criteria of the Oxford Centre for Evidence-Based Medicine. A total of 297 abstracts were found, 14 of which were full articles that met our criteria. Most articles included a study group with chlorhexidine users and a control group with placebo users for oral hygiene in the prevention of pneumonia. All articles were classified as B in the level of evidence, and 12 articles were classified as 2B and two articles as 2C in grade of recommendation. It was observed that the control of oral biofilm reduces the incidence of nosocomial pneumonia, but the fact that most articles had an intermediate grade of recommendation makes clear the need to conduct randomized controlled trials with minimal bias to establish future guidelines for oral hygiene in intensive care units.
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50
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Ewan VC, Sails AD, Walls AWG, Rushton S, Newton JL. Dental and microbiological risk factors for hospital-acquired pneumonia in non-ventilated older patients. PLoS One 2015; 10:e0123622. [PMID: 25923662 PMCID: PMC4414413 DOI: 10.1371/journal.pone.0123622] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 03/01/2015] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Victoria C. Ewan
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
- * E-mail:
| | - Andrew D. Sails
- Public Health England, Microbiology Services, Newcastle Laboratory, Newcastle upon Tyne, United Kingdom
| | - Angus W. G. Walls
- Edinburgh Dental Institute, University of Edinburgh, Edinburgh, United States of America
| | - Steven Rushton
- Biological Modelling, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Julia L. Newton
- Newcastle University Institute for Ageing, Newcastle upon Tyne, United Kingdom
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