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A review of oral preventative strategies to reduce ventilator-associated pneumonia
Abstract
This article evaluates the evidence for and efficacy of the use of mechanical hygiene and chlorhexidine in the prevention of ventilator-associated pneumonia (VAP).
Inclusion criteria: primary research articles; randomized controlled trials; systematic reviews. Exclusion criteria: quasi-experimental trials; opinion articles. Search Engines: PubMed; CINAHL; and EBSCO.
VAP is the commonest infection found in critically ill patients who are mechanically ventilated. It is associated with increased mortality, increased length of stay in intensive care and increased costs.
VAP is a health care-associated infection consistent with the presence of an endotracheal tube and mechanical ventilation for greater than 48 h. Efforts aimed at reducing infection rates include oral decontamination and mechanical hygiene to control the bacteria responsible, since there is an association between changes in bacteria found in the oropharynx and its development. Tooth brushing and the use of an oral antiseptic such as chlorhexidine gluconate are increasingly recommended in ventilator care bundles.
While there have been a number of studies conducted evaluating the efficacy of both approaches, there is limited evidence to support their use. The frequency of oral decontamination and mechanical hygiene interventions have not been established and chlorhexidine 2% seems to be more effective compared to weaker concentrations, but data is mainly confined to patients following cardiothoracic surgery.
... [3][4][5][6][7] This intervention could be achieved through selective digestive decontamination or prophylaxis with a topical antibiotic or antispectic. [6][7][8][9][10] However, the use of antibiotics can induce bacterial resistance. 11 Thus, oral hygiene with chlorhexidine could be an option for the decontamination of the oropharynx and could affect critically ill patients by preventing the occurrence of NP and VAP. ...
... The impossibility of self-care, associated with inadequate oral hygiene, medication use, compromised immune system, therapeutic dehydration and hyposalivation causes an imbalance of the resident microbiota and increases the probability of biofilm colonization by respiratory pathogens in the oral cavity. 4,8 The presence of pathogenic respiratory micro-organisms in the oral biofilm of patients in the ICU lends support to the hypothesis that oropharyngeal decontamination with chlorhexidine may prevent the development of NP and VAP. 9,17,22,23 These highly prevalent conditions in the ICU exert a significant impact on the mortality rate 3,5,6,12,13,20 and represent additional healthcare costs, with prolonged hospitalization, an increase in the need for medications, comorbidities and an increase in the use of healthcare resour ces. ...
Objective:
To summarize evidence regarding the effectiveness of using chlorhexidine for oral healthcare on patients in the intensive care unit for the prevention of nosocomial pneumonia and ventilator-associated pneumonia.
Methods:
This overview of systematic reviews was developed using articles found in PUBMED, Cochrane Library, LILACS, CRD, CINHAL, manual search and grey literature.
Results:
Of the total 16 systematic reviews, 14 included meta-analysis. Most of them were classified with high methodological quality. In seven systematic reviews, chlorhexidine was effective for prevention of nosocomial pneumonia and ventilator-associated pneumonia in adult population in cardiothoracic intensive care unit. The effectiveness was contradictory with other population patients in intensive care units.
Conclusion:
Chlorhexidine has proven to be effective for the prevention of NP among adult populations in cardiothoracic ICU. In ICUs with patients who have varied clinical-surgical conditions, the effectiveness of chlorhexidine for the prevention of PN and VAP was inconclusive.
... As there is an association between changes in oropharyngeal bacteria and development of VAP, there are efforts underway aimed at oral decontamination and mechanical hygiene to control the bacteria responsible for infection. In light of this fact, tooth-brushing and the use of an oral antiseptic such as chlorhexidine are increasingly recommended in ventilator care bundles [9]. ...
... Unfortunately, the definition and implementation of oral hygiene protocols vary widely, and there is limited evidence to support their use. Moreover, the optimal frequency of oral decontamination and mechanical hygiene intervention has yet to be established [9]. A recent online survey showed that oral care was neither standardized nor consistently implemented in the intensive care units of the responding hospitals, and only a small proportion had protocols available for VAP prevention [10]. ...
Healthcare workers are challenged with providing quality care in a variety of clinical settings, while optimizing the use of available resources. Although various novel approaches in preventing hospital-acquired infections (HAIs) have been introduced, best practices have yet to be consolidated. The use of sophisticated technology such as anti-infective devices can improve yields and reduce nosocomial infections while optimizing the use of staff time, but we would emphasize that this benefit is modest in most cases, and is easily undone when the focus of concern lies not in the attention to proper aseptic technique, judicious use, and adequate clinical setting for these devices, but on poor implementation that relies only on their infection-prevention properties. This paper intends to review recent publications in key target areas regarding the prevention of HAIs and to discuss the incorporation of technology to achieve overall improvement in the healthcare setting.
... Poor oral hygiene allows the growth of microbial oral biofilms that increases the number of free microorganisms in the saliva, which in turn enhances the risk for micro-aspiration of microbes into the lungs. A large number of studies have tested the hypothesis that improved oral care helps to prevent ventilator-associated pneumonia 17,18 and nonventilator hospital-associated pneumonia. 6,19,20 To date, evidence suggests that oral hygiene can enhance the efficacy of the ventilator-associated pneumonia prevention bundle. ...
Nonventilator hospital‐associated pneumonia has recently emerged as an important preventable hospital‐associated infection, and is a leading cause of healthcare‐associated infection. Substantial accumulated evidence links poor oral health with an increased risk of pneumonia, which can be caused by bacterial, viral, or fungal pathogens, each with their own distinct mechanisms of transmission and host susceptibility. These infections are frequently polymicrobial, and often include microbes from biofilms in the oral cavity. Evidence documenting the importance of oral care to prevent nonventilator hospital‐associated pneumonia is continuing to emerge. Reduction of oral biofilm in these populations will reduce the numbers of potential respiratory pathogens in the oral secretions that can be aspirated, which in turn can reduce the risk for pneumonia. This review summarizes up‐to‐date information on the role of oral care in the prevention of nonventilator hospital‐associated pneumonia.
... In the literature, existing studies show various results concerning the effects of CHX on the prevention of VAP development and reduction of its incidence. Although some studies report that CHX is effective in preventing VAP occurrence or reducing VAP rate; the others state that it is not effective (AACN Practice Alert, 2017; Andrews & Steen, 2013;Darvishi Khezri et al., 2014;El-Rabbany et al., 2015;Hua et al., 2016;Klompas, Speck, Howell, Greene, & Berenholtz, 2014;Munro & Ruggiero, 2014;Par et al., 2014;Tuon et al., 2017;Zhang et al., 2014). ...
Aim:
Study aims were to determine the most effective chlorhexidine concentration to be used in reducing microbial colonization in patients under mechanical ventilation and to examine the effect of oral care using different concentrations on the integrity of the oral mucous membranes.
Design:
This research was a randomized controlled double-blinded experimental study.
Method:
The sample of study consisted of the 116 adult patients who remained intubated. Oral care was given to patients 4 times/day as per nurse protocol. Every morning during for 4 days, the intraoral mucosa of all groups of patients was assessed. Microbial colonization samples from oral mucosa were taken in the morning before oral care. A determination of the species of microorganisms in these samples was made.
Results:
A statistically significant difference was found with regard to the reproduction of microorganisms between the oral mucosa samples taken from patients using 2% and 1% chlorhexidine solutions (P < 0.001). In the cultures taken from patients on the first and fourth days of intubation, a total of 36 different microorganisms were seen to be reproducing.
Conclusion:
It was concluded that the most effective oral solution for the prevention of microbial colonization in patients under mechanical ventilation was chlorhexidine 1%.
... [15,16] In ICUs in Iran, oral moisturizing is performed using normal saline or lemon juice-glycerin preparation. [17] Normal saline has positive effects on oral lesions. Nonetheless, it dries oral mucosa. ...
Objective
Mouth dryness is one of the most prevalent problems in Intensive Care Units (ICUs). It facilitates dental plaque formation. The aim of this study was to analyze the effects of Aloe vera-Peppermint (Veramin) moisturizing gel on mouth dryness and oral health among patients hospitalized in ICUs.
Methods
This triple-blind two-group randomized placebo-controlled clinical trial was undertaken in 2016–2017 on a convenient sample of 80 patients. Patients were randomly allocated to an intervention and a placebo group. Oral care for patients in the intervention and the placebo groups was provided for 5 successive days using Veramin moisturizing gel and a placebo gel, respectively. Data were collected at the 1st, 3rd, and 5th days of the study using a demographic and clinical characteristics questionnaire, the Challacombe scale (for mouth dryness assessment), and the Mucosal-Plaque Index (for oral health assessment). The Chi-square, Fisher Exact, Mann–Whitney U, and Friedman tests were used for data analysis.
Findings
In the 5th day, the mean score of mouth dryness in the intervention group was significantly lower than the placebo group (P = 0.0001). On the other hand, in the third and the 5th days, the oral health mean score in the intervention group was significantly lower than the placebo group (P = 0.0001).
Conclusion
Veramin moisturizing gel is effective in significantly relieving mouth dryness, preventing dental plaque formation, and improving oral health. Thus, it can be used for improving oral care outcomes in ICUs.
... In the literature, existing studies show various results concerning the effects of CHX on the prevention of VAP development and reduction of its incidence. Although some studies report that CHX is effective in preventing VAP occurrence or reducing VAP rate; the others state that it is not effective (AACN Practice Alert, 2017; Andrews & Steen, 2013;Darvishi Khezri et al., 2014;El-Rabbany et al., 2015;Hua et al., 2016;Klompas, Speck, Howell, Greene, & Berenholtz, 2014;Munro & Ruggiero, 2014;Par et al., 2014;Tuon et al., 2017;Zhang et al., 2014). ...
The aim of this systematic review was to determine the effect of chlorhexidine at different concentration and frequency on ventilator-associated pneumonia and microbial colonization in mechanically ventilated patients. Relevant studies in English language were identified by searching data bases between January 2010 and December 2017. Ten studies met the inclusion criteria. Chlorhexidine with 0.2% concentration was found to be more effective than the control group (placebo dental gel and normal saline) in preventing the development of ventilator-associated pneumonia in three of the eight studies. Twice-daily application was found to be effective reducing the rate of ventilator-associated pneumonia in three studies using 0.2% and 2% chlorhexidine. Microbial colonization was found to be less in 2% chlorhexidine group than herbal mouth wash 0.9% NaCl and 0.2% chlorhexidine in three studies. Chlorhexidine is an effective intervention in oral care for ventilator-associated pneumonia and microbial colonization.
... Among the various concentrations of CHX (0.12%, 0.2%, and 2%), favorable outcomes were more pronounced with CHX 2%. (Ashraf & Ostrosky-Zeichner 2012, Andrews & Steen 2013. We recommend physicians and nurses to promote routine use of oral CHX (0.12%-2%) for oral hygiene in ventilated patients. ...
Ventilator-associated pneumonia (VAP) is the most common nosocomial infection reported among mechanically ventilated patients. VAP is an emerging concept and remains a significant clinical problem for critically ill patients. Although VAP is often preventable, its effects on morbidity, mortality, length of hospital stay, and cost are enormous. VAP is not a new diagnosis, but education and research on the prevention of this serious problem are still continuing. Oropharyngeal colonization is the main risk factor for the development of VAP. Oral health can be compromised by critical illness and mechanical ventilation. It can also be influenced by nursing attentions. Therefore, education and focus on suitable oral care strategies are necessary. Moreover, nursing research to define the best process for all patients in ICU is needed. Whether nursing actions decrease VAP rates remains an empirical question that requires more research since no valid and reliable survey could be found in the literature for oral care practices on orally intubated critically ill patients. An oral care survey for orally intubated patients is hence essential to determine the best existing practices. Many studies have thus attempted to determine the effects of this intervention on the incidence of VAP. The present study aimed to review the literature focusing on oral hygiene in prevention of VAP.
... VAP are associated with mortality rates ranging between 20% and 70% that can be even more important when VAP are caused by multiple drug-resistant pathogens or when the first antibiotic is inadequate [9][10][11]. It is also linked with extended ICU and hospital stay, delay in recovery, and augmented health care expenses [12][13][14]. ...
Background: The resistance to antimicrobial among patients with late Ventilator-associated pneumonia (VAP) has become increasingly more common in many ICUs in Morocco. There are scarce studies assessing VAP importance in Morocco.
The aim of this study is to determine the bacterial ecology and resistance profile of late VAP in intensive care units in an academic hospital of Rabat.
Methods: A total of 215 sputum samples were collected from endotracheal aspirate in patients with diagnosis of late VAP during the study period, defined from April 1st 2012 to April 2013. The bacteriology interpretations was done following the Referential of Medical Microbiology (REMIC 2010) and were quantitatively cultured with a cut-off of ≥ 10 UFC/ml for endotracheal aspiration samples.
Results: Overall, the Gram-negative bacilli (GNB) represent 81.42% of isolates, while Gram-positive was less represented with a rate of 18.56%. Non-lactose fermenting GNB made up the half of pathogens with the rate of 55.23% and the prevalence of Enteric GNB reaches 26.19%. Pseudomonas aeruginosa is the most isolates with the rate of 28.57%, followed by Acinetobacter baumannii (24.76%), Staphylococcus aureus (9.5%) and Klebsiella pneumonia (8.09%). A high level of multi-drug resistance pathogens was found with a rate of 39.52%. They included Pseudomonas aeruginosa (14.28%), Acinetobacter baumannii (19.04%) and Klebsiella pneumonia (5.71%) whereas all S. aureus were methicillin-sensitive.
Conclusion: The local bacterial pathogens isolates displayed high levels of antibiotic resistance. Enteric GNB naturally resistant to Polymyxin E and Corynebacterium species are likely to be emerging pathogens. This study significantly highlights the need to take into account these potentially drug-resistant isolates when making empiric antibiotic treatment.
... The Center for Disease Control and Prevention (CDC) and Institute for Healthcare Improvement (IHI) have introduced recommendations, as the VAP bundle, that include daily oral care with chlorhexidine [11,12]. Oral care is a basic and special nursing care that helps create comfort for patients and prevent VAP [13,14] and generally includes mechanical and pharmacological interventions. ...
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).
... Ventilator-associated pneumonia (VAP) is a very common type of infection in intensive care unit (ICU) patients with a high rate of mortality. It is linked with extended ICU and hospital stay, delay in recovery, and augmented health care expenses (1)(2)(3). Because of the grave consequences of VAP, its prevention has gained the attention of policy makers for developing patients' safety plans (4,5). ...
Background/aim:
The present study aimed to assess the VAP rate and to identify VAP prevention activities in public sector hospitals situated in the Makkah Region, Saudi Arabia (SA).
Materials and methods:
In this cross-sectional study, the VAP data from 13 public sector hospitals were collected from January to December 2013 and analyzed using SPSS 16.
Results:
The overall VAP rate in Makkah Region hospitals was 6.89 cases per 1000 ventilator-days. There was a significant difference in VAP rate among the hospitals of the Makkah Region (P < 0.001). There was no significant difference in the VAP rate among hospitals, which were using only one, two, or all three VAP preventive approaches (P = 0.26) accredited by the Joint Commission International (JCI) and Central Board for Accreditation of Health Care Institution (CBAHI) (P = 0.12), and using the form in intensive care units (ICUs) (P = 0.85). There was a significant difference in the VAP rate among hospitals having different bed capacities (P < 0.001), data regularly collected (P = 0.03), and had a team to supervise the VAP project (P = 0.04).
Conclusion:
The VAP rate in Makkah Region hospitals is 6.89 cases per 1000 ventilator-days.
... Nonetheless, many host-related factors, such as the activation of the complement cascade and the coating of the inner lumen with platelets and serum proteins, enhance bacterial adhesion [15]. Pneumonia due to biofilm formation on endotracheal tubes is a major cause of mortality in intubated patients [16]. Biomaterial associated infections may arise from the formation of biofilms on joint or dental prostheses, intrauterine devices, dental implants and many others. ...
Antimicrobial peptides (AMPs) are an abundant and varied group of molecules recognized as the most ancient components of the innate immune system. They are found in a wide group of organisms including bacteria, plants and animals as a defense mechanism against different kinds of infectious pathogens. Over the past two decades, a fast-growing number of AMPs have been identified/designed and their wide-spectrum antimicrobial activity has been deeply investigated. In recent years, there has been an increasing interest in the use of AMPs as alternative anti-biofilm molecules for the control of biofilm-related infections. Biofilms are sessile communities of microbial cells embedded in a self-produced matrix and characterized by a low metabolic activity. Due to their peculiar physiological properties, bacteria/fungi in biofilms result more resistant to conventional antibiotic therapies compared with their planktonic counterparts. AMPs may be a promising strategy to combat biofilm-related infections, as many of them target the microbial membrane, thus being potentially effective also on metabolically inactive cells. Investigations conducted so far evidenced that these peptides may be active in either eradicating established biofilms or preventing their formation, depending on the specific molecule. Here we present a detailed review of the literature describing the latest results of both in vitro and in vivo experiments aimed at evaluating AMP potential usage in biofilm control. In addition, we provide the reader with an overview on AMP local delivery systems, and we discuss their potential application in the coating of medical indwelling devices.
... Oral antiseptic Chlorhexidine use, its concentration and frequency of adminstration has been associated with reduction of VAP. [39,40,41,42,43,44] Povodine iodine and Iseganan have also been studied for oral decontamination but only povodine iodine demonstrated benefit in VAP reduction. [45,46] Selective oropharygeal decontamination and selective digestive tract decontamination with antibiotic therapy has been associated with only modest mortality benefits [47,48,49] but increases the risk for emergence of antibiotic resistant microorganisms. ...
Ventilator-associated pneumonia (VAP) is a type of hospital acquired pneumonia commonly encountered in patients who receive mechanical ventilation and is associated with significant mortality and morbidity. VAP is associated with prolonged ventilation, increased antibiotic use, emergence of multidrug resistant organisms, prolonged critical care unit stay resulting in increased cost of care. It has been reported to occur in 9 to27 percent of all intubated patients. As per International Nosocomial Infection Control Consortium (INICC) report data summary, the overall rate of VAP was 13.6 per 1,000 ventilator days. Preventive measures, early diagnosis and treatment of VAP result in better outcome. The aim of this review was to search the literature for incidence, various risk factors, etiology, pathogenesis, treatment, and prevention of VAP. A literature search for VAP was done through the PUBMED/MEDLINE database. VAP is a commonly encountered nosocomial infection occurring in ventilated patients and is associated with increased mortality and morbidity. Outcome of patient with VAP depends on hospital setting, patient group, infection control policy, early diagnosis and judicious antibiotic use.
... La mayoría de los estudios sobre las prácticas de higiene se centran en el personal de salud, no en los pacientes y se limitan a la descripción de los elementos instrumentales del procedimiento. Al respecto indican que los cuidados relacionados con la necesidad de higiene más desarrollados son higiene oral, higiene perianal, lavado de manos, sin embargo, se observa deficiente documentación de resultados e impacto y poco reflejo del cuidado de enfermería individualizado (15,39) Se evidencian piezas de investigación y documentales relacionadas con uso de agentes limpiadores, higiene oral y su impacto y asociación con morbilidad y mortalidad por neumonía asociada al ventilador (40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56) . También numerosos artículos relacionados con la higiene de las manos y control de infecciones (57)(58)(59)(60)(61)(62)(63)(64) y programas de control de infecciones (65)(66)(67) . ...
br />Los pacientes hospitalizados en entornos críticos requieren la provisión de cuidados de enfermería para satisfacer sus necesidades básicas. Las intervenciones encaminadas a satisfacer las necesidades de higiene son cuidados de enfermería, inherentes al rol profesional y que actualmente se omiten o delegan por considerarlas de poco valor, sin tener en cuenta que constituyen indicadores de resultado en los pacientes y de la calidad de atención en las unidades de cuidado crítico.
Objetivo: Analizar la importancia social, disciplinar y teórica de la higiene como un cuidado básico de enfermería requerido por los pacientes críticos y su relación con la comodidad a la luz de la teoría propuesta por Kolcaba.
Método: Revisión de la literatura y selección de artículos en las bases de datos ISI -Web of Knowledge, Scopus, Science Direct, Proquest, Ebsco, Medline, Ovid, Scielo y de otras fuentes como documentos no publicados y páginas web. La revisión incluyó 3 estudios cualitativos, 27 cuantitativos, 1 estudio mixto, 40 piezas documentales y 4 editoriales publicados por profesionales de enfermería y otras áreas de la salud.
Resultados: Los resultados se organizaron en 4 categorías así, cuidados básicos de enfermería en entornos críticos, higiene como cuidado básico para los pacientes críticos, higiene y comodidad y necesidades de investigación.
Importancia clínica: Es indispensable que el profesional de enfermería asegure la satisfacción de las necesidades de higiene de los pacientes, así se proporciona seguridad, comodidad y bienestar. Durante la provisión de los cuidados de enfermería se presenta una oportunidad para que el profesional de enfermería se comunique con el paciente, evalúe el estado físico y psicológico, identifique posibles ansiedades y temores, planifique los cuidados y brinde una atención individualizada
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... 6 Many cases of pneumonia are related to oral bacteria emanating from the oropharynx. 12 Given that 70% of UK adults older than 75 years old wear dentures, it is clear that these individuals are at greater risk of developing life-threatening infections due to putative respiratory pathogens residing upon their denture. 13 This recent study showed that patients who wear their denture overnight double their risk of pneumonia. ...
PurposeRecent studies have established a relationship between dental plaque and pulmonary infection, particularly in elderly individuals. Given that approximately one in five adults in the UK currently wears a denture, there remains a gap in our understanding of the direct implications of denture plaque on systemic health. The aim of this study was to undertake a comprehensive evaluation of putative respiratory pathogens residing upon dentures using a targeted quantitative molecular approach.Materials and Methods
One hundred and thirty patients’ dentures were sonicated to remove denture plaque biofilm from the surface. DNA was extracted from the samples and was assessed for the presence of respiratory pathogens by qunatitative polymerase chain reaction (qPCR). Ct values were then used to approximate the number of corresponding colony forming equivalents (CFEs) based on standard curves.ResultsOf the dentures, 64.6% were colonized by known respiratory pathogens. Six species were identified: Streptococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae B, Streptococcus pyogenes, and Moraxella catarrhalis. P. aeruginosa was the most abundant species followed by S. pneumoniae and S. aureus in terms of average CFE and overall proportion of denture plaque. Of the participants, 37% suffered from denture stomatitis; however, there were no significant differences in the prevalence of respiratory pathogens on dentures between healthy and inflamed mouths.Conclusions
Our findings indicate that dentures can act as a reservoir for potential respiratory pathogens in the oral cavity, thus increasing the theoretical risk of developing aspiration pneumonia. Implementation of routine denture hygiene practices could help to reduce the risk of respiratory infection among the elderly population.
Data Science for COVID-19, Volume 2: Societal and Medical Perspectives presents the most current and leading-edge research into the applications of a variety of data science techniques for the detection, mitigation, treatment and elimination of the COVID-19 virus. At this point, Cognitive Data Science is the most powerful tool for researchers to fight COVID-19. Thanks to instant data-analysis and predictive techniques, including Artificial Intelligence, Machine Learning, Deep Learning, Data Mining, and computational modeling for processing large amounts of data, recognizing patterns, modeling new techniques, and improving both research and treatment outcomes is now possible.
The prevalence of coronavirus disease 2019 (COVID-19) exacerbated investor fears, uncertainties, and increased volatility in financial markets. The reaction to oil prices gradually absorbed the epidemic until March 08, but the market situation changed soon with a sharp drop in prices until April 17. This study aims to verify the impact of COVID-19 cases on crude oil prices and the Saudi economy. A simple linear regression estimate shows that new daily outbreaks have a marginally negative impact on crude oil prices in the short term. However, COVID-19 also has an indirect effect on the recent volatility in crude oil prices.
Solutions include proactive management, and we emphasize that special consideration must be given to the size of the supply to properly forecast oil prices. Volatility dominates in the short term. The relationship between the epidemic and oil prices reveals a root cause. Moreover, we investigate the interaction between the epidemic and oil prices, with the effective implementation of these solutions with the government's full support.
The ongoing coronavirus disease 2019 (COVID-19) pandemic is having devastating impacts across the globe. Among the implemented policies to reduce the spread of the disease is lockdown. This might have serious impact on farming activities and the livelihoods of millions of people whose daily means of sustenance is tied to agricultural activities. We undertook this study in West Africa, one of the most fragile and vulnerable regions to the epidemic. Our aim was to understand (1) farmers' perception of the impact of COVID-19 and lockdown policies on their farm or business revenue, (2) farmers' preparedness for COVID-19 lockdown on their farm or business revenue, and (3) the impact of effectiveness of COVID-19 lockdown on their farm or business revenue. We combined online questionnaire, physical contact and administration, and social media (Facebook and WhatsApp) to get responses from 303 farmers in Nigeria and Ghana. Our findings show that COVID-19 and lockdown policies negatively affected the farmers. The impact of COVID-19 and lockdown policies on respondents' farm or business revenue was independent of either age or gender of respondents and the effectiveness of lockdown in both the countries. The status of lockdown in respondent places (locked down versus not locked down) and the level of preparedness of farmers to handle the situation with the current COVID-19 crisis in their farms were also independent in both the countries. However, we found that the impact of COVID-19 and lockdown policies on farm or business revenue depends on the level of preparedness of farmers to handle the situation in each country. We further found that the impact of COVID-19 and lockdown policies on farm or business revenue was independent of the status of lockdown but rather depended on the preparedness for the current COVID-19 crisis and differently across countries. Our findings suggest that building capacities of farmers and supporting them in preparedness for such occurrence, as well as establishing and implementing public policies in this direction, can mitigate the impact of the pandemic on their activities.
According to the World Health Organization (WHO), viral infections continue to emerge and pose severe problems to public health. In mid-December 2019, coronavirus (coronavirus disease 2019 [COVID-19]) infection begun scattering from China. Globally, there are growing worries about community infections, in light of pandemic characterization for the outbreak by the WHO. Some studies have found that 1 out of 7 COVID-19 patients have acquired secondary bacterial infection, and half of the patients who have died had such infections. The challenge of antibiotic resistance could become an enormous force contributing to the rise in illness and death associated with COVID-19, as lower respiratory tract infections are among the leading causes of mortality in critically ill ventilated-patients with COVID-19.
The increasing prevalence of resistance to penicillin and other drugs among pneumococci has considerably complicated the treatment of acquired pneumonia. Resistance to other classes of antibiotics, traditionally used as alternatives in the treatment of pneumococcal infections, has also increased markedly in the recent years. Although the search for new antibiotics remains a top priority, the pipeline for new antibiotics is not encouraging, making it essential to search for other alternative solutions. Researching promising antimicrobial agents that are effective against COVID-19 as well as Streptococcus pneumoniae, which is a major cause of pneumonia, should be encouraged to reduce mortality related to COVID-19 infections. In this chapter, the relation between secondary infections and antibiotic resistance as contributors to high death rate among COVID-19 patients will be traced and highlighted. The possibility of using antimicrobial agents of plant origin, either independently or in combination with nanostructures, as preventive and/or treatment strategies for infections associated with COVID-19 will be reviewed.
The present study aimed to evaluate the in vitro antiseptic efficacy of a mouthwash and a dental gel containing phthalocyanine derivatives (Pc) against bacteria and fungi frequently found in patients with ventilator-associated pneumonia. The experiment in this study was conducted following Good Laboratory Practices. The product was tested at concentrations of 0.015% (mouthwash) and 0.100% (dental gel). The contact time of the suspension test ( Escherichia coli , Pseudomonas aeruginosa , Staphylococcus aureus , Salmonella sp. , Candida albicans , and Aspergillus niger ) was 60 s (1 min). In this analysis, the Phtalox® Mouthwash and Dental Gel resulted in a 99.99% reduction against the tested microorganisms after 1 min of contact time in both products. The Pc-containing mouthwash and dental gel were effective against bacteria and fungi found in patients with ventilator-associated pneumonia.
Background:
The purpose of this study was to explore the use of the oral decontamination solution chlorhexidine (CHX) to reduce ventilator-associated pneumonia (VAP) in a long-term ventilator care setting over time. Most of the research in this area has been conducted in acute and intensive care settings.
Methods:
This study was a retrospective medical record review conducted in a long-term care facility with a dedicated ventilator unit. Veterans records (N = 12) were accessed for this study. The study covered 50 months, with a 43-month time period during which CHX was administered.
Results:
While the sample size was small, many of the veterans on ventilators used CHX for years without an incident of VAP.
Conclusions:
These findings support using CHX to significantly reduce the number of days of intravenous antibiotics used to treat VAP with little side effects.
Patients who are hospitalized in critical care settings require nursing care to meet their basic needs. These interventions are integrated as indicators of patient outcomes and quality of care in critical care units. Objective: To analyze the social relevance and disciplinary nature of hygiene, as basic nursing care required for critically ill patients. Method: A literature review and article selection from the ISI-Web of Knowledge, Scopus, Science Direct, Proquest, Ebsco, Medline, Ovid, and SciELO databases and other sources, such as unpublished documents and web pages. This review included 3 qualitative studies, 27 quantitative studies, 1 mixed study, 40 documentary works, and 4 editorials that were published by nursing professionals and health professionals in other areas. Results: The results were divided into the following 4 categories: basic nursing care in critical care settings, hygiene as basic care for critically ill patients, hygiene and comfort, and research recommendations. Clinical Relevance: It is essential that nursing professionals satisfy patients' hygiene needs and thus provide for their safety, comfort, and welfare. There is an opportunity during the delivery of nursing care for nursing professionals to communicate with patients, assess physical and psychological states, identify potential anxieties and fears, plan patient care, and provide individual attention.
Objective
To evaluate the effectiveness of an electric toothbrush for oral care in patients with neuromuscular disability.Methods
In this randomized observer-blind crossover trial, 30 patients with neuromuscular disease performed either electric or manual toothbrushing each for 4 weeks. Plaque status (plaque control record), periodontal pocket depth, oral status (oral assessment guide), salivary bacterial count, and toothbrushing time were assessed after each period and compared between the two groups by Wilcoxon signed-rank test.ResultsTwenty-eight patients completed the study, including 18 communicative patients. Periodontal pockets were significantly shallower and toothbrushing time was significantly shorter with electric toothbrush use than with manual toothbrush use. No significant differences in oral status and salivary bacterial counts were noted between the approaches, but plaque status significantly improved after electric toothbrushing in communicative patients.Conclusions
Electric toothbrushing is beneficial for maintaining oral health in patients with neuromuscular disability and reducing the caregivers’ oral care burden.
Ventilator-associated pneumonia (VAP) is one of the most commonly encountered hospital-acquired infections in intensive care units and is associated with significant morbidity and high costs of care. The pathophysiology, epidemiology, treatment and prevention of VAP have been extensively studied for decades, but a clear prevention strategy has not yet emerged. In this article we will review recent literature pertaining to evidence-based VAP-prevention strategies that have resulted in clinically relevant outcomes. A multidisciplinary strategy for prevention of VAP is recommended. Those interventions that have been shown to have a clinical impact include the following: (i) Non-invasive positive pressure ventilation for able patients, especially in immunocompromised patients, with acute exacerbation of chronic obstructive pulmonary disease or pulmonary oedema, (ii) Sedation and weaning protocols for those patients who do require mechanical ventilation, (iii) Mechanical ventilation protocols including head of bed elevation above 30 degrees and oral care, and (iv) Removal of subglottic secretions. Other interventions, such as selective digestive tract decontamination, selective oropharyngeal decontamination and antimicrobial-coated endotracheal tubes, have been tested in different studies. However, the evidence for the efficacy of these measures to reduce VAP rates is not strong enough to recommend their use in clinical practice. In numerous studies, the implementation of VAP prevention bundles to clinical practice was associated with a significant reduction in VAP rates. Future research that considers clinical outcomes as primary endpoints will hopefully result in more detailed prevention strategies.
Background:
Microaspiration of vomitus can cause a serious condition known as Mendelson's syndrome. The present study used simulated stomach contents and an airway model to compare a tracheal tube with a tapered cuff (Taper) to the conventional high volume low pressure cuff (HVLP) in their abilities to prevent microaspiration.
Methods:
The automated cuff pressure was adjusted to 10, 20, and 30 cmH2O. We poured 5 ml of simulated stomach contents above the cuff in the vertically situated airway model and measured the leakage volume after 5 minutes as well as 4 hours.
Results:
After 5 minutes, leakage volume was significantly lower for the Taper than for the HVLP at 10 cmH2O, but not for 20 and 30 cmH2O. After 4 hours, stomach content leakage was significantly less with the Taper than with the HVLP, regardless of cuff pressure (P < 0.05).
Conclusions:
We conclude that the Taper may be more effective than the conventional HVLP in preventing vomitus microaspiration in an airway model simulation.
Most of the oral problems affecting patients in the ICU (intensive care unit) are conditions resulting from their general health status/immunosuppression, medications, and trauma due to tracheal intubation. Furthermore, microorganisms present in the oral cavity and oropharynx may be transported into the lungs resulting in pneumonia.
The objectives of this study were to evaluate the oral problems in patients in the ICU of a cancer center and describe the procedures performed by the dentists in such patients.
The sample consisted of 116 patients and 329 procedures performed in the period between May 2007 and July 2011 at A.C. Camargo Cancer Center.
Oral mucositis was the main problem (20.3 %), especially in immunosuppressed patients (p < 0.001). Other most prevalent problems were candidiasis (16.6 %), bacterial biofilm (14.9 %), and xerostomia (7.18 %). The main procedures performed were clinical evaluation and medication prescription corresponding to 35.10 and 27.81 %, respectively.
In conclusion, most of the patients presented oral problems related to side effects of oncological treatment. The dentist's participation in the ICU is important for the prevention, diagnosis, and treatment of oral problems.
Measuring the attributable mortality of ventilator-associated pneumonia (VAP) is challenging and prone to different forms of bias. Studies addressing this issue have produced variable and controversial results.
We estimate the attributable mortality of VAP in a large multicenter cohort using statistical methods from the field of causal inference.
Patients (n = 4,479) from the longitudinal prospective (1997-2008) French multicenter Outcomerea database were included if they stayed in the intensive care unit (ICU) for at least 2 days and received mechanical ventilation (MV) within 48 hours after ICU admission. A competing risk survival analysis, treating ICU discharge as a competing risk for ICU mortality, was conducted using a marginal structural modeling approach to adjust for time-varying confounding by disease severity.
Six hundred eighty-five (15.3%) patients acquired at least one episode of VAP. We estimated that 4.4% (95% confidence interval, 1.6-7.0%) of the deaths in the ICU on Day 30 and 5.9% (95% confidence interval, 2.5-9.1%) on Day 60 are attributable to VAP. With an observed ICU mortality of 23.3% on Day 30 and 25.6% on Day 60, this corresponds to an ICU mortality attributable to VAP of about 1% on Day 30 and 1.5% on Day 60.
Our study on the attributable mortality of VAP is the first that simultaneously accounts for the time of acquiring VAP, informative loss to follow-up after ICU discharge, and the existence of complex feedback relations between VAP and the evolution of disease severity. In contrast to the majority of previous reports, we detected a relatively limited attributable ICU mortality of VAP.
Poor dental hygiene has been linked to respiratory pathogen colonization in residents of long-term care facilities. We sought to investigate the association between dental plaque (DP) colonization and lower respiratory tract infection in hospitalized institutionalized elders using molecular genotyping.
We assessed the dental status of 49 critically ill residents of long-term care facilities requiring intensive care treatment. Plaque index scores and quantitative cultures of DPs were obtained on ICU admission. Protected BAL (PBAL) was performed on 14 patients who developed hospital-acquired pneumonia (HAP). Respiratory pathogens recovered from the PBAL fluid were compared genetically to those isolated from DPs by pulsed-field gel electrophoresis.
Twenty-eight subjects (57%) had colonization of their DPs with aerobic pathogens. Staphylococcus aureus (45%) accounted for the majority of the isolates, followed by enteric Gram-negative bacilli (42%) and Pseudomonas aeruginosa (13%). The etiology of HAP was documented in 10 patients. Of the 13 isolates recovered from PBAL fluid, nine respiratory pathogens matched genetically those recovered from the corresponding DPs of eight patients.
These findings suggest that aerobic respiratory pathogens colonizing DPs may be an important reservoir for HAP in institutionalized elders. Future studies are needed to delineate whether daily oral hygiene in hospitalized elderly would reduce the risk of nosocomial pneumonia in this frail population.
Given the high morbidity and mortality attributable to ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, prevention plays a key role in the management of patients undergoing mechanical ventilation. One of the candidate preventive interventions is the selective decontamination of the digestive or respiratory tract (SDRD) by topical antiseptic or antimicrobial agents. We performed a meta-analysis to investigate the effect of topical digestive or respiratory tract decontamination with antiseptics or antibiotics in the prevention of VAP, of mortality and of all ICU-acquired infections in mechanically ventilated ICU patients.
A meta-analysis of randomised controlled trials was performed. The U.S. National Library of Medicine's MEDLINE database, Embase, and Cochrane Library computerized bibliographic databases, and reference lists of selected studies were used. Selection criteria for inclusion were: randomised controlled trials (RCTs); primary studies; examining the reduction of VAP and/or mortality and/or all ICU-acquired infections in ICU patients by prophylactic use of one or more of following topical treatments: 1) oropharyngeal decontamination using antiseptics or antibiotics, 2) gastrointestinal tract decontamination using antibiotics, 3) oropharyngeal plus gastrointestinal tract decontamination using antibiotics and 4) respiratory tract decontamination using antibiotics; reported enough data to estimate the odds ratio (OR) or risk ratio (RR) and their variance; English language; published through June 2010.
A total of 28 articles met all inclusion criteria and were included in the meta-analysis. The overall estimate of efficacy of topical SDRD in the prevention of VAP was 27% (95% CI of efficacy = 16% to 37%) for antiseptics and 36% (95% CI of efficacy = 18% to 50%) for antibiotics, whereas in none of the meta-analyses conducted on mortality was a significant effect found. The effect of topical SDRD in the prevention of all ICU-acquired infections was statistically significant (efficacy = 29%; 95% CI of efficacy = 14% to 41%) for antibiotics whereas the use of antiseptics did not show a significant beneficial effect.
Topical SDRD using antiseptics or antimicrobial agents is effective in reducing the frequency of VAP in ICU. Unlike antiseptics, the use of topical antibiotics seems to be effective also in preventing all ICU-acquired infections, while the effectiveness on mortality of these two approaches needs to be investigated in further research.
Dental plaque biofilms are colonized by respiratory pathogens in mechanically-ventilated intensive care unit patients. Thus, improvements in oral hygiene in these patients may prevent ventilator-associated pneumonia. The goal of this study was to determine the minimum frequency (once or twice a day) for 0.12% chlorhexidine gluconate application necessary to reduce oral colonization by pathogens in 175 intubated patients in a trauma intensive care unit.
A randomized, double-blind, placebo-controlled clinical trial tested oral topical 0.12% chlorhexidine gluconate or placebo (vehicle alone), applied once or twice a day by staff nurses. Quantitation of colonization of the oral cavity by respiratory pathogens (teeth/denture/buccal mucosa) was measured.
Subjects were recruited from 1 March, 2004 until 30 November, 2007. While 175 subjects were randomized, microbiologic baseline data was available for 146 subjects, with 115 subjects having full outcome assessment after at least 48 hours. Chlorhexidine reduced the number of Staphylococcus aureus, but not the total number of enterics, Pseudomonas or Acinetobacter in the dental plaque of test subjects. A non-significant reduction in pneumonia rate was noted in groups treated with chlorhexidine compared with the placebo group (OR = 0.54, 95% CI: 0.23 to 1.25, P = 0.15). No evidence for resistance to chlorhexidine was noted, and no adverse events were observed. No differences were noted in microbiologic or clinical outcomes between treatment arms.
While decontamination of the oral cavity with chlorhexidine did not reduce the total number of potential respiratory pathogens, it did reduce the number of S. aureus in dental plaque of trauma intensive care patients.
Ventilator-associated pneumonia is associated with increased morbidity and mortality.
To examine the effects of mechanical (toothbrushing), pharmacological (topical oral chlorhexidine), and combination (toothbrushing plus chlorhexidine) oral care on the development of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation.
Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized controlled clinical trial with a 2 x 2 factorial design. Patients with a clinical diagnosis of pneumonia at the time of intubation and edentulous patients were excluded. Patients (n = 547) were randomly assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral swab twice daily, toothbrushing thrice daily, both toothbrushing and chlorhexidine, or control (usual care). Ventilator-associated pneumonia was determined by using the Clinical Pulmonary Infection Score (CPIS).
The 4 groups did not differ significantly in clinical characteristics. At day 3 analysis, 249 patients remained in the study. Among patients without pneumonia at baseline, pneumonia developed in 24% (CPIS >or=6) by day 3 in those treated with chlorhexidine. When data on all patients were analyzed together, mixed models analysis indicated no effect of either chlorhexidine (P = .29) or toothbrushing (P = .95). However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (CPIS >or=6) among patients who had CPIS <6 at baseline (P = .006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine.
Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.
Poor oral hygiene is associated with respiratory pathogen colonization and secondary lung infection. The impact of adding electric toothbrushing to oral care in order to reduce ventilator-associated pneumonia (VAP) incidence is unknown.
The study design was a prospective, simple-blind, randomized trial of adult patients intubated for > 48 h. Controlling for exposure to antibiotic treatment, patients were randomized to oral care every 8 h with 0.12% chlorhexidine digluconate (standard group) or standard oral care plus electric toothbrushing (toothbrush group). VAP was documented by quantitative respiratory cultures. Mechanical ventilation (MV) duration, hospital ICU length of stay (LOS), antibiotic use, and hospital ICU mortality were secondary end points.
The study was terminated after randomizing 147 patients (74 toothbrush group) in a scheduled interim analysis. The two groups were comparable at baseline. The toothbrush group and standard group had similar rates of suspected VAP (20.3% vs 24.7%; p = 0.55). After adjustment for severity of illness and admission diagnosis, the incidence of microbiologically documented VAP was also similar in the two groups (hazard ratio, 0.84; 95% confidence interval, 0.41 to 1.73). The groups did not differ significantly in mortality, antibiotic-free days, duration of MV, or hospital ICU LOS.
Our findings suggest that the addition of electric toothbrushing to standard oral care with 0.12% chlorhexidine digluconate is not effective for the prevention of VAP. Trial registration: ClinicalTrials.gov Identifier: NCT00842478.
Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with major morbidity and attributable mortality. Strategies to prevent VAP are likely to be successful only if based upon a sound understanding of pathogenesis and epidemiology. The major route for acquiring endemic VAP is oropharyngeal colonization by the endogenous flora or by pathogens acquired exogenously from the intensive care unit environment, especially the hands or apparel of health-care workers, contaminated respiratory equipment, hospital water, or air. The stomach represents a potential site of secondary colonization and reservoir of nosocomial Gram-negative bacilli. Endotracheal-tube biofilm formation may play a contributory role in sustaining tracheal colonization and also have an important role in late-onset VAP caused by resistant organisms. Aspiration of microbe-laden oropharyngeal, gastric, or tracheal secretions around the cuffed endotracheal tube into the normally sterile lower respiratory tract results in most cases of endemic VAP. In contrast, epidemic VAP is most often caused by contamination of respiratory therapy equipment, bronchoscopes, medical aerosols, water (eg, Legionella) or air (eg, Aspergillus or the severe acute respiratory syndrome virus). Strategies to eradicate oropharyngeal and/or intestinal microbial colonization, such as with chlorhexidine oral care, prophylactic aerosolization of antimicrobials, selective aerodigestive mucosal antimicrobial decontamination, or the use of sucralfate rather than H(2) antagonists for stress ulcer prophylaxis, and measures to prevent aspiration, such as semirecumbent positioning or continuous subglottic suctioning, have all been shown to reduce the risk of VAP. Measures to prevent epidemic VAP include rigorous disinfection of respiratory equipment and bronchoscopes, and infection-control measures to prevent contamination of medical aerosols. Hospital water should be Legionella-free, and high-risk patients, especially those with prolonged granulocytopenia or organ transplants, should be cared for in hospital units with high-efficiency-particulate-arrestor (HEPA) filtered air. Routine surveillance of VAP, to track endemic VAPs and facilitate early detection of outbreaks, is mandatory.
Several recent studies provide evidence that the oral cavity may influence the initiation and/or the progression of lung diseases such as pneumonia and chronic obstructive pulmonary disease (COPD).
Studies have shown that poor oral hygiene and periodontal disease may foster colonization of the oropharyngeal region by respiratory pathogens, particularly in hospital or nursing home patients. If aspirated, these pathogens can cause pneumonia, one of the most common respiratory infections, especially in institutionalized subjects. Other cross-sectional epidemiologic studies point to an association between periodontal disease and COPD. This systematic review examines the literature to determine if interventions that improve oral hygiene reduce the rate of pneumonia in high-risk populations.
Do periodontal diseases or other indicators of poor oral health influence the initiation/progression of pneumonia or other lung diseases?
MEDLINE, pre-MEDLINE, MEDLINE Daily Update, and the Cochrane Controlled Trials Register were searched to identify published studies that related variables associated with pneumonia and other lung disease to periodontal disease. Searches were performed for articles published in English from 1966 through March 2002.
Randomized controlled clinical trials (RCTs), longitudinal, cohort, and case-control studies were included. Study populations included patients with any form of pneumonia or chronic obstructive pulmonary disease (COPD) and periodontal disease, as measured by assessments of gingival inflammation, probing depth, clinical attachment level, and/or radiographic bone loss, or oral hygiene indices.
Limited to studies of humans.
The summary statistics used to analyze the RCTs included weighted mean differences in rates of disease between control and intervention groups. For cohort studies that measured differences in rates of disease between groups with and without oral disease, weighted mean differences, relative risks, or odds ratios were compared. A meta-analysis was performed on the 5 intervention studies to determine the relationship between oral hygiene intervention and rate of pneumonia in institutionalized patients.
Of the initial 1,688 studies identified, 36 satisfied all inclusion criteria and were read. Of these, 21 (11 case-control and cohort studies [study population 1,413] and 9 RCTs [study population 1,759]) were included in the analysis. 1. A variety of oral interventions improving oral hygiene through mechanical and/or topical chemical disinfection or antibiotics reduced the incidence of nosocomial pneumonia by an average of 40%. 2. Several studies demonstrated a potential association between periodontal disease and COPD.
1. Oral colonization by respiratory pathogens, fostered by poor oral hygiene and periodontal diseases, appears to be associated with nosocomial pneumonia. 2. Additional large-scale RCTs are warranted to provide the medical community with further evidence to institute effective oral hygiene procedures in high-risk patients to prevent nosocomial pneumonia. 3. The results associating periodontal disease and COPD are preliminary and large-scale longitudinal and epidemiologic and RCTs are needed.
The purpose of this study was to discuss the concept of delaying the use of chlorhexidine mouthrinse (CHX) until some time after the use of dentifrice.
Sources included 13 electronic databases, 7 international drug reference books, and the World Wide Web; references of all relevant papers; and further information requested from authors and organizations. Inclusion criteria were a predefined hierarchy of evidence. Study validity was assessed with checklists. Two reviewers independently screened sources, extracted data, and assessed validity.
CHX, a cation, interacts and forms salts of low solubility and antibacterial activity with anions, such as sodium lauryl sulfate (SLS) and sodium monofluorophosphate (MFP). CHX and MFP are not compatible in clinically relevant concentrations in vitro. A 30-minute interval between SLS and CHX rinsing gave a significantly reduced antiplaque effect of CHX, whereas after 2 hours the neutralizing effect of SLS disappeared. Rinsing with dentifrice slurry and CHX produced a significantly increased plaque score compared to CHX and water. In regard to tooth staining by CHX mouthrinses, use of dentifrice before CHX showed a reduction in staining of 18%, whereas CHX followed by dentifrice showed a reduction in staining of about 79%. Literature relating to this interaction is limited; more controlled microbiologic and clinical studies are needed to certify the inaccuracy of this modality of administration.
To optimize the antiplaque effect of CHX, it seems best that the interval between toothbrushing and rinsing with CHX be more than 30 minutes, cautiously close to 2 hours after brushing.
Ventilator-associated pneumonia accounts for 47% of infections in patients in intensive care units. Adherence to the best nursing practices recommended in the 2003 guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention should reduce the risk of ventilator-associated pneumonia.
To evaluate the extent to which nurses working in intensive care units implement best practices when managing adult patients receiving mechanical ventilation.
Nurses attending education seminars in the United States completed a 29-item questionnaire about the type and frequency of care provided.
Twelve hundred nurses completed the questionnaire. Most (82%) reported compliance with hand-washing guidelines, 75% reported wearing gloves, half reported elevating the head of the bed, a third reported performing subglottic suctioning, and half reported having an oral care protocol in their hospital. Nurses in hospitals with an oral care protocol reported better compliance with hand washing and maintaining head-of-bed elevation, were more likely to regularly provide oral care, and were more familiar with rates of ventilator-associated pneumonia and the organisms involved than were nurses working in hospitals without such protocols.
The guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention are not consistently or uniformly implemented. Practices of nurses employed in hospitals with oral care protocols are more often congruent with the guidelines than are practices of nurses employed in hospitals without such protocols. Significant reductions in rates of ventilator-associated pneumonia may be achieved by broader implementation of oral care protocols.
The data presented by Rosenman and Hanna from their study of asthma mortality are consistent with the results of our study (1) and further highlight the need for public health efforts to reduce out-of-hospital asthma deaths, especially for children and young adults. For these younger patients with asthma, we have shown that mortality is quite low for those who are hospitalized. More research is necessary to clearly identify the reasons why these patients are dying without reaching the hospital, and the extent to which interventions earlier in the course of an exacerba-tion can reduce mortality. For now, we believe that efforts should emphasize patient education on how to avoid factors that worsen asthma control, on easy-to-use asthma action plans that enable patients to more quickly recognize and treat asthma exacerba-tions, and on improved access to routine and emergent health care. Conflict of Interest Statement : None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.
To explore the type and frequency of oral care practices in European ICUs and the attitudes, beliefs, and knowledge of health care workers.
An anonymous questionnaire was distributed to representatives of European ICUs. Results were obtained from 59 ICUs (one questionnaire per ICU) in seven countries 91% of respondents were registered nurses.
Of the respondents 77% reported that they had received adequate training on providing oral care; most (93%) also expressed the desire to learn more about oral care. Oral care was perceived to be high priority in mechanically ventilated patients (88%). Cleaning the oral cavity was considered difficult by 68%, and unpleasant as well as difficult by 32%. In 37% of cases respondents felt that despite their efforts oral health worsens over time in intubated patients. Oral care practices are carried out once daily (20%), twice (31%) or three times (37%). Oral care consists principally of mouth washes (88%), mostly performed with chlorhexidine (61%). Foam swabs (22%) and moisture agents (42%) are used less frequently as well as manual toothbrushes (41%) although the literature indicates that these are more effective for thorough cleaning of the oral cavity. Electric toothbrushes were never used.
In European ICUs oral care is considered very important. It is experienced as a task that is difficult to perform, and that does not necessarily succeed in ensuring oral health in patients with prolonged intubation. Oral care consists primarily of mouth washes. The use of toothbrushes should be given more attention.
To evaluate the effect of oral decontamination on the incidence of ventilator associated pneumonia and mortality in mechanically ventilated adults.
Systematic review and meta-analysis.
Medline, Embase, CINAHL, the Cochrane Library, trials registers, reference lists, conference proceedings, and investigators in the specialty.
Two independent reviewers screened studies for inclusion, assessed trial quality, and extracted data. Eligible trials were randomised controlled trials enrolling mechanically ventilated adults that compared the effects of daily oral application of antibiotics or antiseptics with no prophylaxis.
11 trials totalling 3242 patients met the inclusion criteria. Among four trials with 1098 patients, oral application of antibiotics did not significantly reduce the incidence of ventilator associated pneumonia (relative risk 0.69, 95% confidence interval 0.41 to 1.18). In seven trials with 2144 patients, however, oral application of antiseptics significantly reduced the incidence of ventilator associated pneumonia (0.56, 0.39 to 0.81). When the results of the 11 trials were pooled, rates of ventilator associated pneumonia were lower among patients receiving either method of oral decontamination (0.61, 0.45 to 0.82). Mortality was not influenced by prophylaxis with either antibiotics (0.94, 0.73 to 1.21) or antiseptics (0.96, 0.69 to 1.33) nor was duration of mechanical ventilation or stay in the intensive care unit.
Oral decontamination of mechanically ventilated adults using antiseptics is associated with a lower risk of ventilator associated pneumonia. Neither antiseptic nor antibiotic oral decontamination reduced mortality or duration of mechanical ventilation or stay in the intensive care unit.
Ventilator-associated pneumonia is the most common nosocomial infection encountered in the intensive care unit and is usually caused by micro-aspiration of infected secretions from the oropharynx. It is difficult to diagnose accurately with no universally accepted 'gold-standard' diagnostic criteria, leading to both over and under diagnosis. However, its development prolongs length of stay, increases healthcare costs and is an independent risk factor for death. Despite this lack of a clear definition, the incidence of ventilator-associated pneumonia is increasingly being used as a quality indicator within the intensive care unit, highlighting the importance of prevention. Fortunately a number of preventative strategies have been shown to significantly reduce its incidence. These interventions broadly include avoidance of an endotracheal tube; reducing contamination of medical equipment; reducing colonisation of the aerodigestive tract; reducing aspiration of infected secretions; and reducing the duration of mechanical ventilation.
Ventilator-associated pneumonia (VAP) is the first cause of mortality due to nosocomial infections in the intensive care unit. Its incidence ranges from 9% to 67% of patients on mechanical ventilation. Risk factors are multiple and are associated with prolonged stays in hospital and intensive care units. Additional costs for each episode of VAP range from 9,000 € to 31,000 €.Thus, its prevention should be considered as a priority. This prevention could decrease associated morbidity, mortality, costs, and increase patient safety.
Mechanically ventilated patients are at the highest risk for the second most common nosocomial infection, pneumonia. This retrospective study evaluates the impact of a compre- hensive oral care protocol on the ventilator-associated pneumonia (VAP) rate in adult ICU patients. The oral care procedure addresses three recognized VAP risk factors: (1) oropharyngeal colonization, (2) oral secretions that can migrate to the subglottal area and (3) dental plaque. Included are revisions to the policy and procedure, as well as the rationale for procedural components and product selection. Finally, statistical process control methods (SPC) are used to document a decrease in the VAP rate.
#### Summary points
Ventilator associated pneumonia is the most common nosocomial infection in patients receiving mechanical ventilation, and it accounts for about half of all antibiotics given in the intensive care unit (ICU).1 Its reported incidence depends on case mix, duration of mechanical ventilation, and the diagnostic criteria used. It occurs in 9-27% of mechanically ventilated patients, with about five cases per 1000 ventilator days.2 The condition is associated with increased ICU and hospital stay and has an estimated attributable mortality of 9%.3
#### Sources and selection criteria
I searched various sources to identify relevant evidence on the definition, epidemiology, and management of patients with ventilator associated pneumonia. These included PubMed, the Cochrane Library, and conference proceedings. I searched www.clinicaltrials.gov for current research.
A number of evidence based strategies have been described for the prevention of ventilator associated pneumonia, and its incidence can be reduced by combining several in a care bundle.4
The purpose of this review is to update readers on the diagnosis, management, and prevention of this serious infection.
Ventilator associated pneumonia is a hospital acquired pneumonia that occurs 48 hours or more after tracheal intubation.5 It can usefully be classified as early onset or late onset pneumonia. Early onset pneumonia occurs within four days of intubation and mechanical ventilation, and it is generally caused by antibiotic sensitive bacteria. Late onset pneumonia develops after four days …
Evaluate change in ventilator associated pneumonia (VAP) and nurse's attitudes, beliefs post implementation of an evidence based practice (EBP) oral hygiene protocol. METHODOLOGY/DESIGN/SETTING: Descriptive pre and post test design in two critical care units in a Level One Trauma Community Hospital. Oral hygiene protocol data was reanalysed to examine effects in medical surgical and trauma subgroups.
Oral care practices, attitudes and beliefs among nurses, and VAP rates according to Centers for Disease Control and Prevention guidelines.
Trauma rates increased from 6.4% to 10.0% (p=0.346), and medical/surgical rates decreased from 3.3% to 1.0% (p=0.042). Results revealed changes in nurses' beliefs regarding pre-admission colonisation (p=0.027) and having adequate training. Nurses' perception of facility support improved, by having suitable equipment and readily available supplies. Foam swabs with moisture agents at 4hours or less was 88.6% and toothbrush use at 12hours or less was 71%, with significant changes in frequency of oral care post intervention.
Trauma patients present with unique characteristics which compromise oral care. Understanding risk and prognostic factors, mechanisms of transmission and systemic inflammatory response are important when implementing EBP protocols. Nurses' attitudes, beliefs are important, and staff adherence considered when initiating EBP changes.
Ventilator-associated pneumonia (VAP) is the first cause of mortality due to nosocomial infections in the intensive care unit. Its incidence ranges from 9% to 67% of patients on mechanical ventilation. Risk factors are multiple and are associated with prolonged stays in hospital and intensive care units. Additional costs for each episode of VAP range from €9,000 to €31,000.Thus, its prevention should be considered as a priority. This prevention could decrease associated morbidity, mortality, costs, and increase patient safety.ResumenLa neumonía asociada a ventilación mecánica es la primera causa de mortalidad por infecciones nosocomiales en la unidad de cuidados intensivos. Su incidencia oscila entre el 9 y el 67% de los pacientes que requieren ventilación mecánica. Hay múltiples factores de riesgo asociados y aumenta significativamente la estancia en la unidad de cuidados intensivos y en el hospital. El coste adicional por cada neumonía asociada a ventilación mecánica oscila entre 9.000 y 31.000 €.Por tanto, su prevención debe considerarse una prioridad. Ésta podría disminuir tanto la morbimortalidad asociada como el coste de la atención, y mejorar la seguridad del paciente.
Oral care may decrease the development of ventilator-associated pneumonia (VAP) and improve oral hygiene. However, little evidence is available to guide the development of oral care protocols. The practical effect of toothbrushing on VAP development and oral health and hygiene improvement is inconclusive.
This study evaluated the effects in postneurosurgical, intensive care unit patients of brushing teeth twice daily with purified water on VAP rates and oral health or hygiene.
This study conducted a randomized controlled pilot trial. Patients consecutively admitted to the surgical intensive care unit at a suburban hospital in 2007 were invited to participate if they met two inclusion criteria: (a) under ventilator support for at least 48 to 72 hours and (b) no current pneumonia. Upon obtaining informed consent, subjects were randomized into experimental and control groups. Both groups received usual hospital care, that is, daily oral care using cotton swabs. The experimental group additionally received a twice-daily oral care protocol of toothbrushing with purified water, elevating the head of the bed, and before-and-after hypopharyngeal suctioning. The control group also received twice-daily mock oral care (elevating the head of the bed, moisturizing the lips, and before-and-after hypopharyngeal suctioning). VAP was defined by a clinical pulmonary infection score of > 6. Oral hygiene and health was assessed after conclusion of the intervention.
Patients (N = 53) were predominantly male (64.2%), mean age was 60.6 years old, and most had received emergency surgery (75.5%). After 7 days of toothbrushing with purified water, cumulative VAP rates were significantly lower in the experimental (17%) than in the control (71%; p <.05) group. The experimental group also had significantly better scores for oral health (p <.05) and plaque index (p <.01). CONCLUSION/IMPLICATION FOR PRACTICE: Findings suggest that, as an inexpensive alternative to existing protocols, toothbrushing twice daily with purified water reduces VAP and improves oral health and hygiene.
The purpose of this study was to describe the pattern of dental plaque accumulation in mechanically ventilated adults. Accumulation of dental plaque and bacterial colonisation of the oropharynx is associated with a number of systemic diseases including ventilator associated pneumonia. RESEARCH METHODOLOGY/DESIGN: Data were collected from mechanically ventilated critically ill adults (n=137), enrolled within 24 hours of intubation. Dental plaque, counts of decayed, missing and filled teeth and systemic antibiotic use was assessed on study days 1, 3, 5 and 7. Dental plaque averages per study day, tooth type and tooth location were analysed.
Medical respiratory, surgical trauma and neuroscience ICU's of a large tertiary care centre in the southeast United States.
Plaque: all surfaces >60% plaque coverage from day 1 to day 7; molars and premolars contained greatest plaque average >70%. Systemic antibiotic use on day 1 had no significant effect on plaque accumulation on day 3 (p=0.73).
Patients arrive in critical care units with preexisting oral hygiene issues. Dental plaque tends to accumulate in the posterior teeth (molars and premolars) that may be hard for nurses to visualise and reach; this problem may be exacerbated by endotracheal tubes and other equipment. Knowing accumulation trends of plaque will guide the development of effective oral care protocols.
The aim of this review was to critically analyse recent research that has investigated ventilator care bundle (VCB) use, with the objective of analysing its impact on ventilator-associated pneumonia (VAP) outcomes.
The VCB is a group of four evidence-based procedures, which when clustered together and implemented as an 'all or nothing' strategy, may result in substantial clinical outcome improvement. VAP is a nosocomial lung infection associated with endotracheal tube use in ventilated patients. Since the VCB was introduced there have been several studies that have reported significant VAP rate reductions.
A comprehensive search for research, published between 2004 and 2009, was conducted using Medline and PubMed. Key words were used to identify English language studies reporting VCB implementation within adult intensive care units (ICU) and associated clinical outcomes. Studies that implemented bundle variations that did not include all four elements were excluded.
Because of the limitations of the observational designs used in the studies retrieved, a definitive causal relationship between VCB use and VAP reduction cannot be stated. However, the evidence to date is strongly indicative of a positive association. Several studies reported the use of additional VCB elements. In these cases it is difficult to establish which elements are related to the measured outcomes. Further research is recommended to establish baseline outcome measures using the four-element VCB, before adding further processes singly, as well as research investigating the effect of audit and feedback on VCB compliance and its effect on clinical outcomes.
A reduction in VAP is associated with VCB use. The evidence to date, whilst not at the highest experimental level, is at the highest ethically permissible level. In the absence of contradictory research, the current evidence suggests that use of the VCB represents best practice for all eligible adult ventilated patients in ICU.
We did a systematic review and random effects meta-analysis of randomised trials to assess the effect of oral care with chlorhexidine or povidone-iodine on the prevalence of ventilator-associated pneumonia versus oral care without these antiseptics in adults.
Studies were identified through PubMed, CINAHL, Web of Science, CENTRAL, and complementary manual searches. Eligible studies were randomised trials of mechanically ventilated adult patients receiving oral care with chlorhexidine or povidone-iodine. Relative risks (RR) and 95% CIs were calculated with the Mantel-Haenszel model and heterogeneity was assessed with the I(2) test.
14 studies were included (2481 patients), 12 investigating the effect of chlorhexidine (2341 patients) and two of povidone-iodine (140 patients). Overall, antiseptic use resulted in a significant risk reduction of ventilator-associated pneumonia (RR 0.67; 95% CI 0.50-0.88; p=0.004). Chlorhexidine application was shown to be effective (RR 0.72; 95% CI 0.55-0.94; p=0.02), whereas the effect resulting from povidone-iodine remains unclear (RR 0.39; 95% CI 0.11-1.36; p=0.14). Heterogeneity was moderate (I(2)=29%; p=0.16) for the trials using chlorhexidine and high (I(2)=67%; p=0.08) for those assessing povidone-iodine use. Favourable effects were more pronounced in subgroup analyses for 2% chlorhexidine (RR 0.53, 95% CI 0.31-0.91), and in cardiosurgical studies (RR 0.41, 95% CI 0.17-0.98).
This analysis showed a beneficial effect of oral antiseptic use in prevention of ventilator-associated pneumonia. Clinicians should take these findings into account when providing oral care to intubated patients.
None.
Aerobic and facultatively anaerobic gram-negative bacilli (AGNB) are opportunistic pathogens and continue to cause a large number of hospital-acquired infections. AGNB residing in the oral cavity and oropharynx have been linked to nosocomial pneumonia and septicemia. Although AGNB are not considered members of the normal oral and oropharyngeal flora, medically compromised patients have been demonstrated to be susceptible to AGNB colonization.
A literature search was conducted to retrieve articles that evaluated the effectiveness of oral hygiene interventions in reducing the oral and oropharyngeal carriage of AGNB in medically compromised patients.
Few studies have documented the use of mechanical oral hygiene interventions alone against AGNB. Although a number of studies have employed oral hygiene interventions complemented by antiseptic agents such as chlorhexidine and povidone iodine, there appears to be a discrepancy between their in vitro and in vivo effectiveness.
With the recognition of the oral cavity and oropharynx as a reservoir of AGNB and the recent emergence of multidrug and pandrug resistance in hospital settings, there is a pressing need for additional high-quality randomized controlled trials to determine which oral hygiene interventions or combination of interventions are most effective in eliminating or reducing AGNB carriage.
The Clinical Pulmonary Infection Score (CPIS) was developed to serve as a surrogate tool to facilitate the diagnosis of ventilator-associated
pneumonia (VAP). The CPIS is calculated on the basis of points assigned for various signs and symptoms of pneumonia (eg, fever
and extent of oxygenation impairment). Although some studies suggest that a CPIS >6 may correlate with VAP, most studies indicate
that the CPIS has limited sensitivity and specificity. In addition, no well-done studies validate the CPIS in either acute
lung injury or trauma. The interobserver variability in CPIS calculation remains substantial, suggesting that this cannot
be routinely used across multiple centers to support the conduct of randomized clinical trials. Changes in the CPIS may correlate
with outcomes in VAP, but it appears that the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen
is a more important marker for outcomes than the CPIS. At present, the CPIS has a limited role both clinically and as a research
tool.
To investigate the effect of a powered toothbrush on colonization of dental plaque by ventilator-associated pneumonia (VAP)-associated organisms and dental plaque removal.
Parallel-arm, single-centre, examiner- and analyst-masked randomized controlled trial. Forty-six adults were recruited within 48 h of admission. Test intervention: powered toothbrush, control intervention: sponge toothette, both used four times per day for 2 min. Groups received 20 ml, 0.2% chlorhexidine mouthwash at each time point.
The results showed a low prevalence of respiratory pathogens throughout with no statistically significant differences between groups. A highly statistically significantly greater reduction in dental plaque was produced by the powered toothbrush compared with the control treatment; mean plaque index at day 5, powered toothbrush 0.75 [95% confidence interval (CI) 0.53, 1.00], sponge toothette 1.35 (95% CI 0.95, 1.74), p=0.006. Total bacterial viable count was also highly statistically significantly lower in the test group at day 5; Log(10) mean total bacterial counts: powered toothbrush 5.12 (95% CI 4.60, 5.63), sponge toothette 6.61 (95% CI 5.93, 7.28), p=0.002.
Powered toothbrushes are highly effective for plaque removal in intubated patients in a critical unit and should be tested for their potential to reduce VAP incidence and health complications.
This article is an executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide for ventilator-associated pneumonia. Infection preventionists are encouraged to obtain the original, full-length Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide for more thorough coverage of ventilator-associated pneumonia prevention. Copyright © 2010 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Background:
Pneumonia is an important cause of mortality in intensive care units (ICUs). The incidence of pneumonia in ICU patients ranges between 7% and 40%, and the crude mortality from ventilator-associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to pneumonia, it has been shown to contribute to mortality in ICUs independently of other factors that are also strongly associated with such deaths.
Objectives:
To assess the effects of prophylactic antibiotic regimens, such as selective decontamination of the digestive tract (SDD) for the prevention of respiratory tract infections (RTIs) and overall mortality in adults receiving intensive care.
Search strategy:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register; MEDLINE (January 1966 to March 2009); and EMBASE (January 1990 to March 2009).
Selection criteria:
Randomised controlled trials (RCTs) of antibiotic prophylaxis for RTIs and deaths among adult ICU patients.
Data collection and analysis:
At least two review authors independently extracted data and assessed trial quality.
Main results:
We included 36 trials involving 6914 people. There was variation in the antibiotics used, patient characteristics and risk of RTIs and mortality in the control groups. In trials comparing a combination of topical and systemic antibiotics, there was a significant reduction in both RTIs (number of studies = 16, odds ratio (OR) 0.28, 95% confidence interval (CI) 0.20 to 0.38) and total mortality (number of studies = 17, OR 0.75, 95% CI 0.65 to 0.87) in the treated group. In trials comparing topical antimicrobials alone (or comparing topical plus systemic versus systemic alone) there was a significant reduction in RTIs (number of studies = 17, OR 0.44, 95% CI 0.31 to 0.63) but not in total mortality (number of studies = 19, OR 0.97, 95% CI 0.82 to 1.16) in the treated group.
Authors' conclusions:
A combination of topical and systemic prophylactic antibiotics reduces RTIs and overall mortality in adult patients receiving intensive care. Treatment based on the use of topical prophylaxis alone reduces respiratory infections but not mortality. The risk of resistance occurring as a negative consequence of antibiotic use was appropriately explored only in one trial which did not show any such effect.
Several observations from this trial are noteworthy. While the overall number of patients studied (n = 512) was large compared to those in other studies of oral decontamination with chlorhexidine, only approximately one third of patients enrolled in the trial were actually intubated and receiving mechanical ventilation. Previous studies8,9 have focused primarily on intubated patients. Additionally, the patient population studied was different than that found in many ICUs around the world, given the young age of the patients (average age, approximately 36 years), lack of significant medical comorbidities (< 2% with chronic cardiac or respiratory disease), and relatively low acute physiology and chronic health evaluation (APACHE) II scores. Another striking finding in the study was the lower than expected rate of hospital-acquired pneumonia in the control group of 7.7% compared to a rate of 21.7% in patients evaluated in the 3 months before and after the conclusion of the study. The authors speculate that this effect may be due to meticulous oral cleansing. However, this may also be an example of the so-called Hawthorne effect, in which subjects who are singled out for special attention have better outcomes simply due to the increased attention they receive, independent of the intervention performed. As expected, among mechanically ventilated patients, the rates of pneumonia were considerably higher (chlorhexidine group, 15.9%; potassium permanganate group, 18.1%), but the sample sizes may not have been large enough to detect a significant difference in VAP rates between these groups, given the relatively low number of intubated patients.
We assessed the impact of the full protocol of selective decontamination of the digestive tract (SDD) using parenteral and enteral antimicrobials on mortality.
A systematic review was performed searching MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, previous meta-analyses, and conferences proceedings. We included all randomized controlled trials (RCTs) comparing the full protocol of SDD, including oropharyngeal and intestinal administration of antibiotics combined with the parenteral component, with no treatment or placebo. The primary end points were overall mortality, mortality attributable to infection, early, and late mortality.
Twenty-one RCTs on 4902 patients were included. Overall mortality was significantly reduced (odds ratio [OR], 0.71; 95% confidence interval [CI]; 0.61-0.82; P < .001). There was a nonsignificant reduction in infection-related mortality (6 RCTs; OR, 0.40; 95% CI, 0.10-1.59; P = .19) and early mortality (4 RCTs; OR, 0.64; 95% CI, 0.34-1.19; P = 0.16), and a significant reduction in late mortality (5 RCTs; OR, 0.56; 95% CI, 0.40-0.77; P < .001). The subgroup analysis showed a significant mortality reduction in successfully decontaminated patients (OR, 0.58; 95% CI, 0.45-0.77; P < .001), and when parenteral and enteral antimicrobials were administered to every patient receiving treatment in the intensive care unit (OR, 0.59; 95% CI, 0.42-0.82; P < .001).
The findings strongly indicated that the full protocol of SDD reduces mortality in critically ill patients, in particular when successful decontamination is obtained. Eighteen patients should be treated with SDD to prevent one death.
The diagnosis of ventilator-associated pneumonia, VAP, is problematic because of a lack of objective tools that are utilized to make an assessment of bacterial-induced lung injury in a heterogeneous group of hosts. Clinical symptoms and signs are used to identify patients that may have a "lung infection". However, the symptoms and signs can be produced by a myriad of other conditions. Recent clinical data also suggests bacterial-induced pathologic processes occur prior to the onset of the symptoms and signs. Utilizing bacterial culture alone, health care practitioners are forced to wait for days for results and will have to order days of empiric antibiotic therapy. Exploratory molecular studies utilizing clone libraries and molecular arrays for microbial identification document the inability of culture-based techniques to even identify all the microbes involved in VAP. These molecular studies also offer evidence that oral flora present in the lungs of patients with VAP, suggesting aspiration of oral secretions and/or biofilms on endotracheal tubes, supply the bacteria for VAP. Much more investigation is needed to determine the optimal timing of antibiotic treatment and which diagnostic molecular methods can be utilized in the ICU.
To assess the prevalence of oral colonization by respiratory pathogens in a group of ICU patients, with specific attention to dental plaque and the oral mucosa.
Prospective, nonrandomized study with age-matched controls.
Medical ICU in a tertiary-care Veterans Affairs Medical Center and a dental school outpatient preventive dentistry clinic.
Nonconsecutive, unselected patients admitted to the medical ICU during a 2-month period; controls were age-matched patients seen for the first time in the preventive dentistry clinic.
None.
Oral hygienic status was assessed in both groups using a semiquantitative system. Quantitative cultures of dental plaque and buccal mucosa were done within 12 hrs of medical ICU admission and every third day thereafter until discharge/death from the medical ICU. In controls, cultures of plaque and buccal mucosa were done on the initial visit only. Severity of illness of medical ICU patients was quantitated using the Acute Physiology and Chronic Health Evaluation (APACHE II) system and McCabe-Jackson criteria.
Oral hygiene of medical ICU patients was poor. These patients had a mean plaque score (1.9 +/- 0.2) that was significantly greater than that same score seen in outpatients of the preventive dentistry clinic (1.4 +/- 0.1; p less than .005). Plaque and/or oral mucosa of 22 (65%) of 34 medical ICU patients were colonized by respiratory pathogens, in contrast to only four (16%) of 25 preventive dentistry clinic patients (p less than .005). The potential respiratory pathogens cultured from medical ICU patients included methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and ten genera of Gram-negative bacilli. Colonization by respiratory pathogens was statistically associated with concomitant antibiotic therapy within the medical ICU group of patients, but not with severity of illness. Although medical ICU patients tended to have more dental plaque than preventive dentistry clinic patients, there was no statistically significant association noted between the presence of dental plaque and respiratory pathogen colonization.
These findings suggest that bacteria commonly causing nosocomial pneumonia colonize the dental plaque and oral mucosa of intensive care patients. In many cases, this colonization occurs by large numbers of bacteria. Dental plaque may be an important reservoir of these pathogens in medical ICU patients. Efforts to improve oral hygiene in medical ICU patients could reduce plaque load and possibly reduce oropharyngeal colonization.
To document in intensive care unit (ICU) patients the effect of dental plaque antiseptic decontamination on the occurrence of plaque colonization by aerobic nosocomial pathogens and nosocomial infections.
Single-blind randomized comparative study.
A 16-bed adult intensive care unit in a university hospital.
Patients consecutively admitted in the ICU with a medical condition suggesting an ICU stay of 5 days and requiring mechanical ventilation.
After randomization, the treated group received dental plaque decontamination with 0.2% chlorhexidine gel, three times a day during the ICU stay. The control group received standard oral care. SPECIFIC MEASUREMENTS: Dental status was assessed by the Caries-Absent-Occluded index; the amount of dental plaque was assessed by a semi-quantitative plaque index. Bacterial sampling of dental plaque, nasal and tracheal aspirate, blood, and urine cultures were done on days 0, 5, 10, and every week.
Sixty patients were included; 30 in the treated group and 30 in the control one (mean age: 51 +/- 16 years; mean Simplified Acute Physiological Score II: 35 +/- 14 points). On admission, no significant differences were found between both groups for all clinical and dental data. Compared with the control group, the nosocomial infection rate and the incidence densities related to risk exposition were significantly lower in the treated group (18 vs 33% days in the ICU and 10.7 vs 32.3% days of mechanical ventilation; P < 0.05). These results were consistent with a significant preventive effect of the antiseptic decontamination (Odds Ratio: 0.27; 95% CI: 0.09; 0.80) with a 53% relative risk reduction. There was a trend to a reduction of mortality, length of stay, and duration of mechanical ventilation.
An antiseptic decontamination of dental plaque with a 0.2% chlorhexidine gel decreases dental bacterial colonization, and may reduce the incidence of nosocomial infections in ICU patients submitted to mechanical ventilation.
Nosocomial infections affect about 30% of patients in intensive-care units and are associated with substantial morbidity and mortality. Several risk factors have been identified, including the use of catheters and other invasive equipment, and certain groups of patients-eg, those with trauma or burns-are recognised as being more susceptible to nosocomial infection than others. Awareness of these factors and adherence to simple preventive measures, such as adequate hand hygiene, can limit the burden of disease. Management of nosocomial infection relies on adequate and appropriate antibiotic therapy, which should be selected after discussion with infectious-disease specialists and adapted as microbiological data become available.
People who need ventilation (mechanical breathing support) in intensive care can develop respiratory tract infections or pneumonia (a lung infection). Some people will die because of these infections. The review of trials found that a combination of antibiotics that are topical (where a drug is applied directly to the part being treated) and systemic (affecting the whole body) reduces mortality and infections. The use of topical antibiotics alone will reduce the person's infection but not influence their survival.
The purpose of this study was to describe the effect of an early post-intubation oral application of chlorhexidine gluconate on oral microbial flora and ventilator-associated pneumonia.
Thirty-four intubated patients were randomly assigned to chlorhexidine gluconate by spray or swab or to control group. Oral cultures were done at study admission, 12, 24, 48, and 72 hours, whereas the Clinical Pulmonary Infection Score (CPIS) was documented at study admission, 48, and 72 hours.
Reductions in oral culture scores (less growth) were only found in the treatment groups (swab and spray); no reduction was found in the control group. There was a trend for fewer positive cultures in the combined treatment groups. The mean CPIS for the control group increased to a level indicating pneumonia (4.7 to 6.6), whereas the CPIS for the treatment group increased only slightly (5.17 to 5.57).
Trends in the data suggest that use of chlorhexidine gluconate in the early post-intubation period may mitigate or delay the development of ventilator-associated pneumonia.
Intensive care unit (ICU) patients have complex oral care needs. Inadequate oral care may predispose ICU patients to nosocomial infections. Recent initiatives have sought to improve the quality and evidence base of ICU oral care provision.
To describe the current priority given to oral care, the knowledge and practice of oral needs assessment and oral care methods, and adherence to the local ICU oral care protocol of ICU nurses working in one hospital.
Self-administered questionnaire survey of all nurses working in adult ICU ( n = 160 ).
Replies were received from 103 (response rate 64.5%). On average, oral care was given a similar priority to other aspects of personal care. 13.5% nurses rated oral care as a low priority. Whilst 98% nurses routinely performed an oral needs assessment, only 26% used a written assessment tool. Toothbrushes were used at least once a day by 85.5% nurses and chlorhexidine products were routinely used by 50.5% nurses. The oral care practices of most nurses matched the local ICU protocol. 23.5% nurses had received no training in oral care and 58% nurses requested initial/further training.
Most oral care methods were appropriate, based on the available evidence. A small minority of nurses gave oral care a low priority and were not using evidence-based oral care methods recommended in the local ICU protocol. Encouraging the general use of oral needs assessment tools is a priority, and further oral care training is required.
Research has shown that oral care involving toothbrushes and topical antimicrobials improves the oral health of medically compromised patients and may reduce the incidence of nosocomial infections including pneumonia. This survey research was undertaken to determine the type and frequency of oral care in intensive care units (ICUs) in the United States and the attitudes, beliefs, and knowledge of health care workers.
A randomly selected survey of 102 ICUs within the continental United States participated with 556 respondents; 97% of respondents were registered nurses.
Frequency and type of oral care provided, attitudes and beliefs, and knowledge and training in oral care were measured.
Ninety-two percent of respondents perceived oral care to be a high priority. The primary methods of oral care involved the use of foam swabs, moisturizers, and mouthwash. Toothbrushes and toothpaste were used infrequently by almost 80% of respondents. The majority of nurses indicated a need for research-proven oral care standards and desired to learn more.
In this random sample of ICUs, oral care methods were not consistent with current research and oral care protocols. The translation of oral care research into practice in the ICU may improve the quality of care and decrease the incidence of ventilator-associated pneumonia.
The present article reviews the association between microbial colonization of the oral cavity and the lungs in critically ill patients that develop ventilator-associated pneumonia (VAP) in the intensive care unit (ICU) setting. The risk factors and microorganisms associated with VAP are presented. The role of oral colonization of VAP-associated pathogens (VAP-AP) in the development of VAP is examined. We explore the potential factors involved in oral colonization of VAP-AP, which are atypical bacteria for the oral cavity. Strategies for the prevention or moderation of oral colonization of VAP-AP have had limited success. We need a deeper understanding of the pathophysiology of VAP in order to reduce the morbidity, mortality, and cost from this common complication in ICU medicine and surgery.
Because of the high morbidity and mortality associated with health-care-associated pneumonia, it is important to implement evidence-based prevention measures. Recently by CDC published Guidelines for Preventing Health-Care-Associated Pneumonia describe prevention measures based on evaluated studies, randomized controlled trials or meta-analyses. In this paper the most important prevention measures are given, as well as the evidence classification. "Among the changes in the recommendations to prevent bacterial pneumonia, especially ventilator-associated pneumonia, are the preferential use of or tracheal rather than naso-tracheal tubes in patients who receive mechanically assisted ventilation, the use of noninvasive ventilation to reduce the need for and duration of endotracheal intubation, changing the breathing circuits of ventilators when they malfunction or are visibly contaminated, and (when feasible) the use of an endotracheal tube with a dorsal lumen to allow drainage of respiratory secretions."
Hospital acquired or nosocomial infections continue to be an important cause of morbidity and mortality. The critically ill patient is at particular risk of developing intensive care unit acquired infection, with the lungs being especially vulnerable. Nosocomial bacterial pneumonia occurring after two days of mechanical ventilation is referred to as ventilator associated pneumonia, and is the most common nosocomial infection seen in the intensive care unit. Intubation of the trachea and mechanical ventilation is associated with a 7-fold to 21-fold increase in the incidence of pneumonia and up to 28% of patients receiving mechanical ventilation will develop this complication. Its development is associated with an attributable increase in morbidity and mortality. The establishment of an accurate diagnosis of ventilator associated pneumonia remains problematic and as yet there is still no accepted "gold standard" for diagnosis. The responsible pathogens vary according to case mix, local resistance patterns, and methodology of sampling. However, there is general agreement that rapid initiation of appropriate antimicrobial therapy improves outcome.
To assess the efficacy of topical chlorhexidine for prevention of ventilator-associated pneumonia (VAP) in a meta-analysis.
Computerized PubMed and MEDLINE search supplemented by manual searches for relevant articles.
Randomized controlled trials evaluating efficacy of topical chlorhexidine applied to the oropharynx vs. placebo or standard care for prevention of VAP.
Data were extracted on patient population, inclusion and exclusion criteria, diagnostic criteria for VAP, form and concentration of topical chlorhexidine used, incidence of VAP, and overall mortality.
Data on incidence of VAP and mortality were abstracted as dichotomous variables. Pooled estimates of the relative risk and 95% confidence intervals were obtained using the DerSimonian and Laird random effects model and the Mantel-Haenszel fixed effects model. Heterogeneity was assessed using the Cochran Q statistic and I. Subgroup analyses were used to explore heterogeneity.
Seven randomized controlled trials met the inclusion criteria. Topical chlorhexidine resulted in a reduced incidence of VAP (relative risk, 0.74; 95% confidence interval, 0.56-0.96; p=.02) using a fixed effects model. Using the more conservative random effects model, the point estimate was similar (relative risk, 0.70; 95% confidence interval, 0.47-1.04; p=.07), but the results failed to achieve statistical significance. The I test showed moderate heterogeneity. Subgroup analysis showed that the benefit of chlorhexidine was most marked in cardiac surgery patients (relative risk, 0.41; 95% confidence interval, 0.17-0.98; p=.04). There was no mortality benefit with chlorhexidine although the sample size was small.
Our analysis showed that topical chlorhexidine is beneficial in preventing VAP; the benefit is most marked in cardiac surgery patients. A large randomized trial is needed to determine the impact of topical chlorhexidine on mortality.
Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients.
To develop evidence-based guidelines for the prevention of VAP.
MEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials.
The authors systematically searched for all relevant randomized, controlled trials and systematic reviews on the topic of prevention of VAP in adults that were published from 1980 to October 1, 2006.
Independently and in duplicate, the panel scored the internal validity of each trial. Effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. Scores for the safety, feasibility, and economic issues were assigned based on consensus of the guideline panel.
The following statements were used: recommend, consider, do not recommend, and no recommendation due to insufficient or conflicting evidence.
To prevent VAP: We recommend: that the orotracheal route of intubation should be used for intubation; a new ventilator circuit for each patient; circuit changes if the circuit becomes soiled or damaged, but no scheduled changes; change of heat and moisture exchangers every 5 to 7 days or as clinically indicated; the use of a closed endotracheal suctioning system changed for each patient and as clinically indicated; subglottic secretion drainage in patients expected to be mechanically ventilated for more than 72 hours; head of bed elevation to 45 degrees (when impossible, as near to 45 degrees as possible should be considered). Consider: the use of rotating beds; oral antiseptic rinses. We do not recommend: use of bacterial filters; the use of iseganan We make no recommendations regarding: the use of a systematic search for sinusitis; type of airway humidification; timing of tracheostomy; prone positioning; aerosolized antibiotics; intranasal mupirocin; topical and/or intravenous antibiotics.
There are a growing number of evidence-based strategies for VAP prevention, which, if applied in practice, may reduce the incidence of this serious nosocomial infection.
Guidelines for Preventing Health-care-associated Pneumonia. Atlanta: CDC. Center for Disease Control Improving surveillance for ventilator-associated events in adults
- Disease Center
- Control
Center for Disease Control. (2003). Guidelines for Preventing Health-care-associated Pneumonia. Atlanta: CDC. Center for Disease Control. (2012). Improving surveillance for ventilator-associated events in adults. http://www.thoracic.org/ about/ats-stat/resources/ATS_VAE_COMPLIANT_FINAL_ 20120301.pdf (accessed 02/03/12).
Associations between peridontal disease and risk for nosocomial bacterial pneumo-nia and chronic obstructive pulmonary disease
- Fa Scannapieco
- Bush Rb
- S Paju
Scannapieco FA, Bush RB, Paju S. (2003). Associations between peridontal disease and risk for nosocomial bacterial pneumo-nia and chronic obstructive pulmonary disease. A Systematic Review. Annals of Peridontology; 8: 54–69.
Institute for Healthcare Improvement. www.ihi.org (accessed 06
- Cambridge
- Ma
Cambridge, MA: Institute for Healthcare Improvement. www.ihi.org (accessed 06/03/12)..
Technical patient safety solutions for ventilator-associated pneumonia in adults
National Institute for Clinical Excellence. (2008). Technical patient
safety solutions for ventilator-associated pneumonia in adults.
London: National Institute of Clinical Management.
The role of oral microbial colonization in ventilator-associated pneumonia
- Brennan