Nosocomial pneumonia: importance of the oral environment

Update on Focal Infection Management: A Czech Interdisciplinary Consensus

BACKGROUND

The focal infection theory has been used to explain several chronic systemic diseases in the past. Systemic diseases were thought to be caused by focal infections, such as caries and periodontal diseases, and dentists were held responsible for these diseases due to the spread of oral infections. As knowledge of the interrelationship between oral microorganisms and the host immune response has evolved over the last few decades, the focal infection theory has been modified in various ways. The relationship between oral and systemic health appears to be more complex than that suggested by the classical theory of focal infections. Indeed, the contribution of the oral microbiota to some systemic diseases is gaining acceptance, as there are strong associations between periodontal disease and atherosclerotic vascular disease, diabetes, and hospital-associated pneumonia, amongst others. As many jurisdictions have various protocols for managing this oral-systemic axis of disease, we sought to provide a consensus on this notion with the help of a multidisciplinary team from the Czech Republic.

METHODS

A multidisciplinary team comprising physicians/surgeons in the specialities of dentistry, ear-nose and throat (ENT), cardiology, orthopaedics, oncology, and diabetology were quetioned with regard to their conceptual understanding of the focal infection theory particularly in relation to the oral-systemic axis. The team also established a protocol to determine the strength of these associations and to plan the therapeutic steps needed to treat focal odontogenic infections whenever possible.

RESULTS

Scoring algorithms were devised for odontogenic inflammatory diseases and systemic risks, and standardised procedures were developed for general use.

CONCLUSIONS

The designed algorithm of the oral-systemic axis will be helpful for all health care workers in guiding their patient management protocol.

Prevalence of Enterococcus species in adults with periodontal health or with periodontitis: a systematic review

The aim of this study was to evaluate the prevalence of Enterococcus species in the mouth of adults with periodontal health and periodontitis. A systematic search was made in databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search for articles was conducted in Medline/PubMed, Latin American and Caribbean Health Sciences Literature Database (LILACS), Cochrane Library, Scopus, Embase, Web of Science databases and in the System of Information on Grey Literature in Europe (SINGLE) and included articles published in English up to April 25th, 2021. Observational studies in humans with and without periodontitis were evaluated to identify the prevalence of Enterococcus species. Articles that met the inclusion criteria were analyzed and classified to determine the quality rating in good, fair, and poor. A new detailed checklist for quality assessment was developed based on the information required for applicable data extraction in reviews. The study design, sample size, demographic data, periodontal clinical parameters, microbial analysis method, biological sample, prevalence of Enterococcus spp., and correlations with periodontal clinical parameters were assessed. After screening and full-text reading, 8 articles met the inclusion criteria. All selected studies showed a significantly higher prevalence of Enterococcus spp. in patients with periodontitis compared with periodontally healthy patients. Thus, the present systematic review suggests that the prevalence of Enterococcus faecalis in the mouth of periodontitis individuals is higher than that of periodontally healthy individuals.

Pathogen Burden Among ICU Patients in a Tertiary Care Hospital in Hail Saudi Arabia with Particular Reference to β-Lactamases Profile

Purpose

Ventilator-associated pneumonia (VAP) is associated with a higher mortality risk for critical patients in the intensive care unit (ICU). Several strategies, including using β-lactam antibiotics, have been employed to prevent VAP in the ICU. However, the lack of a gold-standard method for VAP diagnosis and a rise in antibiotic-resistant microorganisms have posed challenges in managing VAP. The present study is designed to identify, characterize, and perform antimicrobial susceptibility of the microorganisms from different clinical types of infections in ICU patients with emphasis on VAP patients to understand the frequency of the latter, among others.

Patients and Methods

A 1-year prospective study was carried out on patients in the ICU unit at a tertiary care hospital, Hail, Saudi Arabia.

Results

A total of 591 clinically suspected hospital-acquired infections (HAI) were investigated, and a total of 163 bacterial isolates were obtained from different clinical specimens with a high proportion of bacteria found associated with VAP (70, 43%), followed by CAUTI (39, 24%), CLABSI (25, 15%), and SSI (14, 8.6%). Klebsiella pneumoniae was the most common isolate 39 (24%), followed by Acinetobacter baumannii 35 (21.5%), Pseudomonas aeruginosa 25 (15.3%), and Proteus spp 23 (14%). Among the highly prevalent bacterial isolates, extended-spectrum beta-lactamase was predominant 42 (42.4%).

Conclusion

Proper use of antibiotics, continuous monitoring of drug sensitivity patterns, and taking all precautionary measures to prevent beta-lactamase-producing organisms in clinical settings are crucial and significant factors in fending off life-threatening infections for a better outcome.

Microbial resistance to oral antiseptics used in hospitalized patients: A systematic scoping review of randomized clinical trials

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.

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

BACKGROUND

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

METHODS

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

CONCLUSION

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

TRIAL REGISTRATION

PROSPERO Research registration identifying number: CRD42020146932.

Rapid Increase of Oral Bacteria in Nasopharyngeal Microbiota After Antibiotic Treatment in Children With Invasive Pneumococcal Disease

Introduction

Antibiotics are commonly prescribed to young children for treating bacterial infections such as invasive pneumococcal disease (IPD) caused by Streptococcus pneumoniae. Despite the obvious benefits of antibiotics, little is known about their possible side effects on children’s nasopharyngeal microbiota. In other ecological niches, antibiotics have been described to perturb the balanced microbiota with short- and long-term effects on children’s health. The present study aims to evaluate and compare the nasopharyngeal microbiota of children with IPD and different degree of antibiotic exposure.

Methods

We investigated differences in nasopharyngeal microbiota of two groups of children <18 years with IPD: children not exposed to antibiotics before sample collection (n=27) compared to children previously exposed (n=54). Epidemiological/clinical data were collected from subjects, and microbiota was characterized by Illumina sequencing of V3-V4 amplicons of the 16S rRNA gene.

Results

Main epidemiological/clinical factors were similar across groups. Antibiotic-exposed patients were treated during a median of 4 days (IQR: 3–6) with at least one beta-lactam (100.0%). Higher bacterial richness and diversity were found in the group exposed to antibiotics. Different streptococcal amplicon sequence variants (ASVs) were differentially abundant across groups: antibiotic use was associated to lower relative abundances of Streptococcus ASV2 and Streptococcus ASV11 (phylogenetically close to S. pneumoniae), and higher relative abundances of Streptococcus ASV3 and Streptococcus ASV12 (phylogenetically close to viridans group streptococci). ASVs assigned to typical bacteria from the oral cavity, including Veillonella, Alloprevotella, Porphyromonas, Granulicatella, or Capnocytophaga, were associated to the antibiotic-exposed group. Common nosocomial genera such as Staphylococcus, Acinetobacter, and Pseudomonas were also enriched in the group exposed to antibiotics.

Conclusion

Our results point toward a reduction of S. pneumoniae abundance on the nasopharynx of children with IPD after antibiotic treatment and a short-term repopulation of this altered niche by oral and nosocomial bacteria. Future research studies will have to evaluate the clinical implications of these findings and if these populations would benefit from the probiotic/prebiotic administration or even from the improvement on oral hygiene practices frequently neglected among hospitalized children.

Oral and tracheal microbiota of pediatric and adolescent patients in an intensive care unit

OBJECTIVE

To characterize the oral and tracheal microbiota of patients admitted to a pediatric intensive care unit (PICU).

METHODS AND RESULTS

This is an exploratory study conducted on patients aged 5 months to 13 years admitted to the PICU of a referral hospital. Two microbiological samples were collected with a swab in the posterior region of the tongue from patients receiving spontaneous and mechanical ventilation within the first 24 and 48 h after admission to the PICU. Among patients receiving mechanical ventilation, tracheal secretion was also collected in a second sampling. The caries experience was evaluated using the DMFT/dmf index, and the quality of oral hygiene was assessed based on the visual plaque index (VPI). A questionnaire was applied to obtain data on hospital routine and sample characteristics. The DMFT/dmf index was 1.66 (SD = 2.18) and the mean VPI was 43.03 (SD = 36.93). The most prevalent microorganisms were Klebsiella pneumoniae (15%). Oral colonization by opportunistic pathogens was significantly higher in patients receiving mechanical ventilation compared to those on spontaneous ventilation (p < .05). There was no relationship of VPI or DMFT/dmf with oral microbiological changes.

CONCLUSION

The results indicate that PICU patients are susceptible to colonization by respiratory and opportunistic pathogens since the first hours of hospitalization.

Pathogenesis-Targeted Preventive Strategies for Multidrug Resistant Ventilator-Associated Pneumonia: A Narrative Review

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU), accounting for relevant morbidity and mortality among critically ill patients, especially when caused by multidrug resistant (MDR) organisms. The rising problem of MDR etiologies, which has led to a reduction in treatment options, have increased clinician’s attention to the employment of effective prevention strategies. In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing MDR-VAP. Oral hygiene with Chlorhexidine (CHX), CHX body washing, selective oral decontamination (SOD) and/or digestive decontamination (SDD), multiple decontamination regimens, probiotics, subglottic secretions drainage (SSD), special cuff material and shape, silver-coated endotracheal tubes (ETTs), universal use of gloves and contact isolation, alcohol-based hand gel, vaporized hydrogen peroxide, and bundles of care have been addressed. The most convincing evidence came from interventions directly addressed against the key factors of MDR-VAP pathogenesis, especially when they are jointly implemented into bundles. Further research, however, is warranted to identify the most effective combination.

Toothbrushes may convey bacteria to the cystic fibrosis lower airways

Recent findings indicate that the oral cavity acts as a bacterial reservoir and might contribute to the transmission of bacteria to the lower airways. Control of a potentially pathogenic microbiota might contribute to prevent the establishment of chronic infection in cystic fibrosis. We evaluated the presence of CF microorganisms in saliva and toothbrushes of CF patients and verify their possible transmission to lower airways. Methods: We assessed the presence of P. aeruginosa, S. aureus, S. maltophilia, A. xylosoxidans, S. marcescens, and yeasts in saliva, toothbrushes and sputum of 38 CF patients and assessed the clonal identity of the strains occurring contemporary in multiple sites by PFGE. Results: At least one of the investigated species was isolated from 60 saliva samples and 23 toothbrushes. S. aureus was the most abundant species, followed by Candida spp. 31 patients contemporary had the same species in sputum and saliva/toothbrush: in most cases, clonal identity of the strains among the different sites was confirmed. Conclusion: Toothbrushes may be sources of oral contamination and might act as reservoirs favoring transmission of potentially pathogenic microorganisms from the environment to the oral cavity and eventually to the LAW. Oral hygiene and toothbrush care are important strategies to prevent CF lung infections.

Differential molecular approach and ESBL detection from Klebsiella pneumoniae and Escherichia coli isolated from the supraglottic region of patients undergoing mechanical ventilation in an intensive care unit

Introduction: Given their ability for colonizing the supraglottic region, desiccation tolerance, resistance to β-lactam antibiotics, and adherence to both inert surfaces and epithelial cells, Klebsiella pneumoniae and Escherichia coli are potentially pathogenic microorganisms for patients undergoing mechanical ventilation in an intensive care unit (ICU).Objective: To perform a molecular characterization and detection of extended spectrum β-lactamases (ESBL) in K. pneumoniae and E. coli strains isolated from the supraglottic region of patients undergoing mechanical ventilation in an ICU.Materials and methods: A descriptive study was conducted in 18 isolates. Disk diffusion technique was used for detecting ESBL-producing bacteria. Molecular characterization was made by BOX-PCR technique, while ESBL production was confirmed by testing the isolates against cefotaxime and ceftazidime, alone and in combination with clavulanic acid.Results: a K. pneumoniae strain and another E. coli strain were confirmed as ESBL producers. A divergence greater than 50% was observed in most of the strains; besides non-infectious origin strains resistant to third generation cephalosporins were found.Conclusion: The polyclonality found in this study might indicate that most of the strains belong to each patient’s microbiota.

Evaluation of Knowledge of the Oral Hygiene Protocol by the Nursing Team of the Intensive Care Unit of Two Hospitals In Londrina/PR

AbstractOral hygiene in the Intensive Care Unit - ICU is considered a basic and indispensable procedure whose goal is to maintain the patients’ healthy oral conditions, reducing complications and contributing to their recovery. The objective of this study was to evaluate the knowledge on  the oral hygiene protocol by the ICU nursing team of two hospitals in Londrina/PR. The sample of this study was composed by the nursing and nursing technicians team of the Intensive Care Unit of the Hospital A and Hospital B, regardless of gender or age, and considering who had worked at the ICU for at least three months. A self-administered, unidentified questionnaire was used to collect data. The analyzed variables were: profession, age, sex, working time and oral hygiene. More than 80% of the professionals were Nursing Technicians, with average age above 30, female and working in the ICU of the hospital for over 3.5 years. The results of this study demonstrate the lack of knowledge of the oral hygiene protocol by more than 30% of the Nursing staff in both hospitals. Based on the  methodology and the results analysis, it can be concluded that the oral hygiene protocol is unknown by more than a third of the ICU Nursing team of both  surveyed hospitals. Keywords: Intensive Care Units. Disease Prevention. Oral Hygiene.ResumoA higiene bucal em Unidade de Terapia Intensiva - UTI é considerada um procedimento básico e indispensável cujo objetivo é manter saudáveis as condições bucais dos pacientes, reduzindo agravos e contribuindo para sua recuperação. O objetivo deste estudo foi avaliar o conhecimento do protocolo de higiene bucal pela equipe de enfermagem da UTI de dois hospitais em Londrina/PR. A amostra deste estudo foi composta pela equipe de Enfermagem (Enfermeiros e Técnicos em Enfermagem) da Unidade de Terapia Intensiva do Hospital A e do Hospital B, independente do sexo e idade, e que trabalhavam na UTI, no mínimo, há três meses. Para a coleta de dados foi utilizado um questionário autoaplicável, não identificado. As variáveis analisadas foram: profissão, idade, sexo, tempo de trabalho e higiene bucal. Mais de 80% dos profissionais eram Técnicos em Enfermagem, com idade média acima dos 30 anos de idade, do sexo feminino e atuando na UTI do hospital, em média, acima de 3,5 anos. Os resultados deste estudo demonstram a falta de conhecimento do protocolo de higiene bucal, por mais de 30% da equipe de Enfermagem, em ambos os hospitais. Com base na metodologia e análise dos resultados, pode-se concluir que o protocolo de higiene bucal é desconhecido por mais de um terço da equipe de Enfermagem da UTI de ambos os hospitais pesquisados.Palavras-chave: Unidades de Terapia Intensiva. Prevenção de doenças. Higiene Bucal.

The importance of hospital dentistry: oral health status in hospitalized patients

ABSTRACT Objective: This research study aimed to evaluate the oral health status and the need for dental treatment in hospitalized patients, analyzing the importance of dentistry in hospitals. Therefore, the goal of this research study was to evaluate the oral health status, the need for dental intervention and the patient’s opinion about the importance of having dental surgeons in hospital settings. Methods: 103 hospitalized patients were evaluated considering the DMFT index, gingival condition, visible biofilm index, and the need for invasive dental treatment. Volunteers were also asked about their opinion considering the importance of dentistry in hospital settings. Results: 68.9% of volunteers were male subjects and 31.1% female subjects. The mean DMFT was 17.9 and 96.1% of subjects had their oral hygiene kit with when came to hospital, 97.1% of subjects stated that the presence of dental surgeons is necessary in the hospital setting and 63.1% of subjects presented poor biofilm removal. The need for invasive dental treatment was as follows: restorations (68.9%), extractions (40.8%), endodontics (23.3%), dental pain (26.2%) and presence of abscess (7,8%). Conclusion: Oral health and hygiene status of patients were classified as poor and most of patients showed the need for invasive dental treatment. The majority of patients reported that dental care is very important in hospitals settings.

Analysis of biofilm production by clinical isolates of Pseudomonas aeruginosa from patients with ventilator-associated pneumonia

Objective

To phenotypically evaluate biofilm production by Pseudomonas aeruginosa clinically isolated from patients with ventilator-associated pneumonia.

Methods

Twenty clinical isolates of P. aeruginosa were analyzed, 19 of which were from clinical samples of tracheal aspirate, and one was from a bronchoalveolar lavage sample. The evaluation of the capacity of P. aeruginosa to produce biofilm was verified using two techniques, one qualitative and the other quantitative.

Results

The qualitative technique showed that only 15% of the isolates were considered biofilm producers, while the quantitative technique showed that 75% of the isolates were biofilm producers. The biofilm isolates presented the following susceptibility profile: 53.3% were multidrug-resistant, and 46.7% were multidrug-sensitive.

Conclusion

The quantitative technique was more effective than the qualitative technique for the detection of biofilm production. For the bacterial population analyzed, biofilm production was independent of the susceptibility profile of the bacteria, demonstrating that the therapeutic failure could be related to biofilm production, as it prevented the destruction of the bacteria present in this structure, causing complications of pneumonia associated with mechanical ventilation, including extrapulmonary infections, and making it difficult to treat the infection.

Association between pathogens from tracheal aspirate and oral biofilm of patients on mechanical ventilation

The aim of this study was to detect possible associations between respiratory pathogens from tracheal aspirate and oral biofilm samples in intubated patients in an intensive care unit (ICU), and to identify the most common respiratory pathogens in oral biofilm, particularly in patients that developed ventilator-associated pneumonia (VAP). Two oral biofilm samples were collected from the tongue of intubated patients (at admission and after 48 hours) and analyzed by culture with the Antibiotic Sensitivity Test. The results from the tongue biofilm samples were compared with the tracheal secretions samples. A total of 59.37% of patients exhibited the same species of pathogens in their tracheal aspirate and oral biofilm, of which 8 (42.1%) developed VAP, 10 (52.63%) did not develop pneumonia and one (5.26%) had aspiration pneumonia. There was a statistically significant association between presence of microorganisms in the tracheal and mouth samples for the following pathogens: Klebsiella pneumoniae, Candida albicans, Pseudomonas aeruginosa, Enterobacter gergoviae, Streptococcus spp and Serratia marcescens (p < 0.05). Pathogens that are present in tracheal aspirates of intubated patients can be detected in their oral cavity, especially in those who developed VAP or aspiration pneumonia. Thus, the results indicate that an improved oral care in these patients could decrease ICU pneumonia rates.

Prospective, randomised, controlled study evaluating early modification of oral microbiota following admission to the intensive care unit and oral hygiene with chlorhexidine

OBJECTIVES

Chlorhexidine (CHX) is the most commonly used oral hygiene product for the prevention of ventilator-associated pneumonia (VAP) in patients undergoing mechanical ventilation (MV). The change in dental plaque (DP) microbiota following CHX use in patients under MV has not been described previously. The aim of this study was to evaluate the incidence of pathogenic bacteria associated with VAP and the coverage of DP within the oral cavity in patients administered CHX.

METHODS

This was a prospective, randomised, controlled, double-blind study in patients (n=16) under MV who were mouth-rinsed with either CHX or placebo. Microbiology samples were collected from the oral mucosa (OM) and DP after admission to the ICU and on Days 3, 5, 7 and 10. Minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) of CHX were determined.

RESULTS

Upon admission, the occurrence of multidrug-resistant (MDR) bacteria, including carbapenem-resistant Klebsiella pneumoniae, was reported. The CHX group had a lower incidence of methicillin-resistant Staphylococcus aureus (MRSA) compared with the placebo group for the OM (RR=0.51, 95% CI 0.27-0.98; P=0.011). There was high agreement between the culture results of OM and DP (κ=0.825). VAP developed in six patients. The species identified following tracheal aspiration of VAP patients were similar to those found in the OM for four cases. The strains showed low MICs and MBCs for CHX (<0.039mg/mL).

CONCLUSIONS

Although DP is rapidly colonised by MDR bacteria, use of 2% CHX reduced the incidence of S. aureus colonisation.

Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate

BACKGROUND

Ventilator-associated pneumonia (VAP) in neonates can be reduced by implementing preventive care practices. Implementation of a group, or bundle, of evidence-based practices that improve processes of care has been shown to be cost-effective and to have better outcomes than implementation of individual single practices.

PURPOSE

The purpose of this article is to describe a safe, effective, and efficient neonatal VAP prevention protocol developed for caregivers in the neonatal intensive care unit (NICU). Improved understanding of VAP causes, effects of care practices, and rationale for interventions can help reduce VAP risk to neonatal patients.

METHOD

In order to improve care practices to affect VAP rates, initial and annual education occurred on improved protocol components after surveying staff practices and auditing documentation compliance.

FINDINGS/RESULTS

In 2009, a tertiary care level III NICU in the Midwestern United States had 14 VAP cases. Lacking evidence-based VAP prevention practices for neonates, effective adult strategies were modified to meet the complex needs of the ventilated neonate. A protocol was developed over time and resulted in an annual decrease in VAP until rates were zero for 20 consecutive months from October 2012 to May 2014.

IMPLICATIONS FOR PRACTICE

This article describes a VAP prevention protocol developed to address care practices surrounding hand hygiene, intubation, feeding, suctioning, positioning, oral care, and respiratory equipment in the NICU.

IMPLICATIONS FOR RESEARCH

Implementation of this VAP prevention protocol in other facilities with appropriate monitoring and tracking would provide broader support for standardization of care. Individual components of this VAP protocol could be studied to strengthen the inclusion of each; however, bundled interventions are often considered stronger when implemented as a whole.

Clinical assessment of the oral cavity of patients hospitalized in an intensive care unit of an emergency hospital

Objective

To describe the oral health status of patients hospitalized in an intensive care unit.

Methods

Clinical assessment of the oral cavity was performed in 35 patients at two time-points (up to 48 hours after admission and 72 hours after the first assessment) and recorded in data collection forms. The following data were collected: plaque index, condition of the mucosa, presence or absence of dental prosthesis, number of teeth present, and tongue coating index.

Results

The prevalence of nosocomial infection was 22% (eight patients), with 50% respiratory tract infections. All patients exhibited oral biofilm, and 20 (57%) showed biofilm visible to the naked eye; tongue coating was present on more than two thirds of the tongue in 24 patients (69%) and was thick in most cases. A significant increase in plaque index (p=0.007) occurred after 72 hours, although the tongue coating index was p<0.001 regarding the area and p=0.5 regarding the thickness.

Conclusion

The plaque and tongue coating indices increased with the length of hospital stay at the intensive care unit.

Oral care and nosocomial pneumonia: a systematic review

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.

Pseudomonas aeruginosa and Periodontal Pathogens in the Oral Cavity and Lungs of Cystic Fibrosis Patients: a Case-Control Study

Cystic fibrosis (CF) is the most frequent lethal genetic disease in the Caucasian population. Lung destruction is the principal cause of death by chronic Pseudomonas aeruginosa colonization. There is a high prevalence of oropharyngeal anaerobic bacteria in sputum of CF patients. This study was carried out due to the lack of results comparing subgingival periodontal pathogenic bacteria between the oral cavity and lungs in patients with CF in relation with P. aeruginosa presence. Our first goal was to detect P. aeruginosa in oral and sputum samples by culture and molecular methods and to determine clonality of isolates. In addition, subgingival periodontal anaerobic bacteria were searched for in sputum. A cross-sectional pilot case-control study was conducted in the CF Reference Center in Roscoff, France. Ten CF patients with a ΔF508 homozygous mutation (5 chronically colonized [CC] and 5 not colonized [NC]) were enrolled. P. aeruginosa was detected in saliva, sputum, and subgingival plaque samples by real-time quantitative PCR (qPCR). Subsequently, periodontal bacteria were also detected and quantified in subgingival plaque and sputum samples by qPCR. In CC patients, P. aeruginosa was recovered in saliva and subgingival plaque samples. Sixteen P. aeruginosa strains were isolated in saliva and sputum from this group and compared by pulsed-field gel electrophoresis (PFGE). Subgingival periodontal anaerobic bacteria were found in sputum samples. A lower diversity of these species was recovered in the CC patients than in the NC patients. The presence of the same P. aeruginosa clonal types in saliva and sputum samples underlines that the oral cavity is a possible reservoir for lung infection.

Enterobacteriaceae isolates from the oral cavity of workers in a Brazilian oncology hospital

The evaluation of workers as potential reservoirs and disseminators of pathogenic bacteria has been described as a strategy for the prevention and control of healthcare-associated infections (HAIs). The aim of this study was to evaluate the presence of Enterobacteriaceae in the oral cavity of workers at an oncology hospital in the Midwest region of Brazil, as well as to characterize the phenotypic profile of the isolates. Saliva samples of 294 workers from the hospital's healthcare and support teams were collected. Microbiological procedures were performed according to standard techniques. Among the participants, 55 (18.7%) were colonized by Enterobacteriaceae in the oral cavity. A total of 64 bacteria were isolated, including potentially pathogenic species. The most prevalent species was Enterobacter gergoviae (17.2%). The highest rates of resistance were observed for β-lactams, and 48.4% of the isolates were considered multiresistant. Regarding the enterobacteria isolated, the production of ESBL and KPC was negative. Nevertheless, among the 43 isolates of the CESP group, 51.2% were considered AmpC β-lactamase producers by induction, and 48.8% were hyper-producing mutants. The significant prevalence of carriers of Enterobacteriaceae and the phenotypic profile of the isolates represents a concern, especially due to the multiresistance and production of AmpC β-lactamases.

Upper aero-digestive contamination by Pseudomonas aeruginosa and implications in Cystic Fibrosis

BACKGROUND

Cystic Fibrosis (CF) is a severe genetic disorder that is common among the Caucasian population. Bacterial respiratory infections are the main cause of morbidity and mortality in CF patients. Pseudomonas aeruginosa is the main pathogen of lower airways (LAW) decline.

METHOD

To understand chronic broncho-pulmonary colonization, a systematic review is conducted. The aim of our article is to identify the pathways of contamination in the upper aero-digestive tract.

RESULTS

A large number of articles report that P. aeruginosa is established first at nasopharyngeal sites. The vast majority of authors agree that the upper aero-digestive tract is the first location of colonization by P. aeruginosa and its presence appears to be predictive of subsequent broncho-pulmonary colonization.

CONCLUSION

This review supports the possible involvement of the nasal and paranasal sinuses and oral cavity as means of contamination.

Guideline-adherent initial intravenous antibiotic therapy for hospital-acquired/ventilator-associated pneumonia is clinically superior, saves lives and is cheaper than non guideline adherent therapy

INTRODUCTION

Hospital-acquired pneumonia (HAP) often occurring as ventilator-associated pneumonia (VAP) is the most frequent hospital infection in intensive care units (ICU). Early adequate antimicrobial therapy is an essential determinant of clinical outcome. Organisations like the German PEG or ATS/ IDSA provide guidelines for the initial calculated treatment in the absence of pathogen identification. We conducted a retrospective chart review for patients with HAP/VAP and assessed whether the initial intravenous antibiotic therapy (IIAT) was adequate according to the PEG guidelines.

MATERIALS AND METHODS

We collected data from 5 tertiary care hospitals. Electronic data filtering identified 895 patients with potential HAP/VAP. After chart review we finally identified 221 patients meeting the definition of HAP/VAP. Primary study endpoints were clinical improvement, survival and length of stay. Secondary endpoints included duration of mechanical ventilation, total costs, costs incurred on the intensive care unit (ICU), costs incurred on general wards and drug costs.

RESULTS

We found that 107 patients received adequate initial intravenous antibiotic therapy (IIAT) vs. 114 with inadequate IIAT according to the PEG guidelines. Baseline characteristics of both groups revealed no significant differences and good comparability. Clinical improvement was 64% over all patients and 82% (85/104) in the subpopulation with adequate IIAT while only 47% (48/103) inadequately treated patients improved (p< 0.001). The odds ratio of therapeutic success with GA versus NGA treatment was 5.821 (p<0.001, [95% CI: 2.712-12.497]). Survival was 80% for the total population (n = 221), 86% in the adequately treated (92/107) and 74% in the inadequately treated subpopulation (84/114) (p = 0.021). The odds ratio of mortality for GA vs. NGA treatment was 0.565 (p=0.117, [95% CI: 0.276-1.155]). Adequately treated patients had a significantly shorter length of stay (LOS) (23.9 vs. 28.3 days; p = 0.022), require significantly less hours of mechanical ventilation (175 vs. 274; p = 0.001), incurred lower total costs (EUR 28,033 vs. EUR 36,139, p = 0.006) and lower ICU-related costs (EUR 13,308 vs. EUR 18,666, p = 0.003). Drug costs for the hospital stay were also lower (EUR 4,069 vs. EUR 4,833) yet not significant. The most frequent types of inadequate therapy were monotherapy instead of combination therapy, wrong type of penicillin and wrong type of cephalosporin.

DISCUSSION

These findings are consistent with those from other studies analyzing the impact of guideline adherence on survival rates, clinical success, LOS and costs. However, inadequately treated patients had a higher complicated pathogen risk score (CPRS) compared to those who received adequate therapy. This shows that therapy based on local experiences may be sufficient for patients with low CPRS but inadequate for those with high CPRS. Linear regression models showed that single items of the CPRS like extrapulmonary organ failure or late onset had no significant influence on the results.

CONCLUSION

Guideline-adherent initial intravenous antibiotic therapy is clinically superior, saves lives and is less expensive than non guideline adherent therapy. Using a CPRS score can be a useful tool to determine the right choice of initial intravenous antibiotic therapy. The net effect on the German healthcare system per year is estimated at up to 2,042 lives and EUR 125,819,000 saved if guideline-adherent initial therapy for HAP/VAP were established in all German ICUs.

Respiratory disease and the role of oral bacteria

The relationship between oral health and systemic conditions, including the association between poor oral hygiene, periodontal disease, and respiratory disease, has been increasingly debated over recent decades. A considerable number of hypotheses have sought to explain the possible role of oral bacteria in the pathogenesis of respiratory diseases, and some clinical and epidemiological studies have found results favoring such an association. This review discusses the effect of oral bacteria on respiratory disease, briefly introduces the putative biological mechanisms involved, and the main factors that could contribute to this relationship. It also describes the role of oral care for individuals who are vulnerable to respiratory infections.