No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Effectiveness of oral chlorhexidine for the prevention of nosocomial pneumonia and ventilator-associated pneumonia in intensive care units: Overview of systematic reviews
Abstract
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.
... A. baumannii has been identified as a common cause of colonization in endotracheal tubes of intubated patients [20][21][22]. Colonization of this microorganism in the ETT of patients is an important risk factor for nosocomial pneumonia. Furthermore, A. baumannii has been linked to the formation of biofilms on various surfaces that provide the bacteria with protection from antibiotics, allowing them to survive in hostile environments [23,24]. ...
... The reduction in VAP caused by the CHX 0.12%-0.2% achieved is substantial [20]. Despite its effectiveness in treating CRAB colonization, there have been some reports of adverse side effects, such as oral trauma, when CHX is used for prolonged periods of time in endotracheal tube colonization. ...
... SLYG) in 2010, UMMC from 2008 to 2009, HUSM from 2003 to 2006 and 2005 to 2009, UKMMC from 2010 to 2011, and UMMC from 1987 to 1987 and 1996 to 1998. A variety of data was acquired in 2010 and 2011 from various hospitals in the state of Perak, mostly in the area of the town of Ipoh; in 2011 from HSNZ; and in 2011 and 2012 from Hospital Sultanah Aminah (HSA)[19,20]. Carbapenem resistance rates for Malaysian Acinetobacter spp. isolates. ...
Acinetobacter baumannii (A. baumannii) has become a major hospital-acquired infectious agent and is rapidly developing resistance to antimicrobials that are routinely prescribed. Carbapenem-resistant A. baumannii (CRAB) was one of the strains that had been resist to carbapenem. The CRAB has ability in biofilm formation that can lead to severe nosocomial infection. It gained popularity recently for being associated with devastating soft tissue infections in humans mostly in healthcare workers and patients admitted in ICUs. The amount of data currently available provides support to the theory that rising infection rates are caused by the widespread contamination of progressively resistant A. baumannii in hospitals.
... Rabello et al. hanno pubblicato una panoramica di 16 revisioni sistematiche (di cui 14 con metanalisi), dalla quale emergeva che la CHX collutorio era efficace nella prevenzione delle polmoniti nosocomiali e delle VAP in TI soltanto nella popolazione dei pazienti cardiotoracici adulti [12] . Questa popolazione presenta caratteristiche peculiari quali periodi di intubazione mediamente molto brevi (12-24 ore) e inoltre molti pazienti vanno incontro ad interventi chirurgici di elezione, e questo li porta ad essere in generale in condizioni più favorevoli rispetto a case mix caratterizzati da variabili condizioni cliniche [12] . ...
... Rabello et al. hanno pubblicato una panoramica di 16 revisioni sistematiche (di cui 14 con metanalisi), dalla quale emergeva che la CHX collutorio era efficace nella prevenzione delle polmoniti nosocomiali e delle VAP in TI soltanto nella popolazione dei pazienti cardiotoracici adulti [12] . Questa popolazione presenta caratteristiche peculiari quali periodi di intubazione mediamente molto brevi (12-24 ore) e inoltre molti pazienti vanno incontro ad interventi chirurgici di elezione, e questo li porta ad essere in generale in condizioni più favorevoli rispetto a case mix caratterizzati da variabili condizioni cliniche [12] . Infine, i pazienti che si sottopongono a chirurgia valvolare, nel periodo preoperatorio si sottopongono a cure odontoiatriche per eliminare il rischio di infezioni e questo comporta probabilmente una condizione migliore del cavo orale rispetto ad altre tipologie di pazienti in TI [12] . ...
... Questa popolazione presenta caratteristiche peculiari quali periodi di intubazione mediamente molto brevi (12-24 ore) e inoltre molti pazienti vanno incontro ad interventi chirurgici di elezione, e questo li porta ad essere in generale in condizioni più favorevoli rispetto a case mix caratterizzati da variabili condizioni cliniche [12] . Infine, i pazienti che si sottopongono a chirurgia valvolare, nel periodo preoperatorio si sottopongono a cure odontoiatriche per eliminare il rischio di infezioni e questo comporta probabilmente una condizione migliore del cavo orale rispetto ad altre tipologie di pazienti in TI [12] . Infatti, la CHX è molto efficace nell'inibizione dell'accumulo di placca batterica dentale quando viene utilizzata su substrati detersi, in quanto si lega alla mucosa pulita e viene rilasciata nel tempo e per questo si ipotizza che abbia maggior efficacia nei pazienti cardiotoracici [13] . ...
Introduzione: L’igiene del cavo orale rappresenta uno dei pilastri all’interno dei “fundamental of careâ€, trovando nel paziente critico con device endotracheale, in particolar modo quello ricoverato in terapia intensiva, una particolare ragion d’essere non soltanto nel mantenimento del comfort, ma anche e soprattutto nella prevenzione delle polmoniti associate a ventilazione meccanica (VAP). La clorexidina (CHX) collutorio o gel, usata in ambito odontoiatrico con ottimi risultati sull’abbattimento della placca batterica dentale, è diventata oggetto di attenzioni della ricerca clinica.
... Accurate systemic investigations carried out by a multidisciplinary team lead to correct diagnostics and treatment plan. Tongue coating microbiological analysis can be an important strategy, but it is not performed as routine in ICU, be it due to lack of knowledge by hospital teams or to the cost of performing such an investigation for each hospitalized patient, since its hospitalization [4,13,14]. ...
... It is essential pointing out that most patients in intensive care units are elderlies with some type of systemic complexity who need full support in order to help treatment and recovery [15,16], as shown in the current study. The difficulty in having a standardized oral hygiene routine in ICU, with emphasis on tongue dorsum associated with hospitalization time, favors coating accumulation, which is seen as a complex bacterial niche closely associated with hospital infections [5,6,9,11,13]. ...
... The proper microbiological investigation of the oral biofilm as hospital routine, mainly in ICU patients, is not yet a routine. It is only requested when there is any doubt about the diagnostic or the need of specific investigation [4,13,19]. Thus, this microbiological investigation strategy can contribute to better pharmacological management and treatment strategies. ...
Objective
ssess quantitatively and qualitatively tongue coating microbiota in ICU patients.
Methods
Analytical observational study, convenience sample comprising 65 patients was included for medical report analysis and collection of general data, tongue coating assessment through visual inspection and microbiological sample collection for further laboratory analysis. The collection was performed by a single examiner using a sterile swab introduced and rubbing the posterior portion of the tongue close to the oropharynx.
Results
Most patients (60%) belonged to the female sex, at mean age of 74.2 years. The main reasons for hospitalization were lung issues (26.2%) - prevailing associated comorbidities were diabetes (43.1%) and high blood pressure (66.2%). The mean length of stay in the ICU was one day. All patients presented tongue dorsum coating. There were Candida albicans (37%), Streptococcus parasanguinis (26.1%) and Streptococcus mitis (32.6%) in 1/3 of lingual extension. Streptococcus mitis (p=0,0265) was the most prevalent species.
Conclusion
There was no significance between the amount of coating and number of observed species, although all assessed patients had presented coating. The most prevalent microorganisms were Candida albicans, Streptococcus parasanguinis and Streptococcus mitis.
Indexing terms
Biofilms; Hospital assistance; Intensive care unit; Microbiology; Oral health
... Todavia, esse enxaguatório apresenta efeitos colaterais mínimos e reversíveis com a suspensão do uso, como sabor desagradável, irritação leve da mucosa, coloração dos dentes e disgeusia. Porém, apesar desses efeitos, seu benefício supera as desvantagens (31). ...
... Assim, é importante ressaltar que a cavidade bucal funciona como foco no conjunto de agentes capazes de produzir patologias, como endocardite bacteriana, doenças periodontais e candidíase bucal, e que manter os cuidados vão além do conforto, sendo essencial para reduzir modificações na microbiota e o desenvolvimento de infecções (6,25). Portanto, estudos demonstraram a importância da HB em pacientes em uso de VM e a redução das taxas da infecção após a implementação de um protocolo de cuidados bucais (1,6,7,10,17,18,22,25,31). ...
... Em outro estudo, para identificar os cuidados de enfermagem em pacientes em VM na UTI, despontou que, entre as intervenções prescritas, manter a cabeceira elevada a 30º e checar o posicionamento do tubo orotraqueal ou da traqueostomia foram os cuidados de enfermagem mais encontrados (34). Dessa forma, os autores apontam a importância de aperfeiçoamentos sobre o uso de protocolos de prevenção de PAVM, contribuindo assim para a redução do tempo de internação, das complicações e das infecções associados à VM (25,27,31). ...
A pneumonia associada à ventilação mecânica (PAVM) é um tipo de infecção recorrente em pacientes críticos sob internação na Unidade de Terapia Intensiva (UTI) e apresenta altos índices de morbimortalidade. Sua patogênese decorre da introdução de bacilos da microbiota oral passados do tubo orotraqueal para o trato respiratório inferior, funcionando como um potencial reservatório de material infeccioso. O objetivo desse estudo foi avaliar os conhecimentos de uma equipe de enfermagem de UTI sobre a Higiene Bucal em pacientes críticos sob internação e, a partir das informações obtidas, elaborar um material informativo sobre as principais questões apontadas. Foi um estudo exploratório, descritivo e quantitativo realizado em duas etapas: a aplicação de um questionário para analisar os conhecimentos da equipe sobre os métodos de higiene bucal, como medida de prevenção da enfermidade; e a elaboração de um folheto educativo com abordagens sobre o tema, no intuito de informar e atualizar os participantes. Obteve a colaboração de 65 profissionais, em sua maioria do sexo feminino e da faixa etária entre 31-40 anos. Sobre a higiene bucal no paciente em ventilação mecânica, a maior parte respondeu não ter recebido informações sobre o tema durante a formação profissional, bem como não ter conhecimento do protocolo destinado a este procedimento na Instituição de trabalho. Em sua totalidade, consideraram importante a higiene bucal em pacientes críticos. No entanto, a maioria não a associou com a prevenção de PAVM. Assim, a implantação e supervisão de ações interdisciplinares de promoção à saúde bucal em pacientes críticos sob internação é capaz de promover uma conduta padronizada e uma melhor assistência ao indivíduo na UTI.
... Chlorhexidine (CHX) is a broad-spectrum cationic biocide that is effective against both gram-positive and gram-negative bacteria (Block, 2001). Previous studies have reported that using CHX reduces the incidence of ventilator-associated pneumonia (VAP) significantly (Kes et al., 2021;Rabello et al., 2018;Veitz-Keenan & Ferraiolo, 2017). A systematic review conducted by Rabello et al. (2018) concluded that oral hygiene care with CHX, ranging from CHX concentrations of 0.05% to 0.20%, has a protective effect against HAP and VAP. ...
... Previous studies have reported that using CHX reduces the incidence of ventilator-associated pneumonia (VAP) significantly (Kes et al., 2021;Rabello et al., 2018;Veitz-Keenan & Ferraiolo, 2017). A systematic review conducted by Rabello et al. (2018) concluded that oral hygiene care with CHX, ranging from CHX concentrations of 0.05% to 0.20%, has a protective effect against HAP and VAP. In addition, 0.12% CHX is the most common concentration of CHX currently used in oral hygiene care. ...
... VOL. 00, NO. 00, Month 2022 of VAP (Rabello et al., 2018). However, the preventive effect of oral CHX on NV-HAP in middle-aged and elderly inpatients has not yet been determined. ...
Background:
Nonventilator hospital-associated pneumonia (NV-HAP) is a nosocomial infection with a multifactorial etiology that is particularly prevalent in individuals with poor oral health.
Purpose:
This study was designed to determine the effect of a 0.12% chlorhexidine gluconate oral rinse intervention on oral health and on reducing NV-HAP in inpatients.
Methods:
A randomized, double-blind, and triple-arm clinical trial was conducted on a sample of 103 patients aged ≥ 50 years. Using the blocking sample method, patients were randomly assigned into three groups. These included Group A, using an oral rinse solution of 0.12% chlorhexidine; Group B, using Listerine; and Group C, using a standard saline oral rinse. In addition to routine hospital-associated pneumonia preventative nursing care, the participants used the oral rinse solutions twice a day with a period of at least 9 hours between each use. Oral health, the degree of bacterial exposure, and the clinical pneumonia index scale were evaluated in each of the groups at baseline (first day), on Intervention Days 3 and 7, and at discharge. The clearance rate was calculated by dividing the number of bacteria cleared by the total frequency of oral bacteria in the collected culture × 100%.
Results:
Each arm of the study was composed of 34-35 participants, with an average hospitalization duration of 7.5 days. There was no incidence of NV-HAP or any changes in clinical pulmonary infection score among the three groups. Group A achieved a more significant improvement in oral health assessment tool scores between baseline and discharge than either Group B or C (p = .03), particularly in the tongue, gums, and tissues; saliva; and oral cleanliness subscales. In addition, Group A reported higher clearance rates for Staphylococcus (100.00% vs. 66.67% vs. 66.67%, respectively), Escherichia coli (100.00% vs. 60.00% vs. 66.67%, respectively), and Pseudomonas aeruginosa (75.00% vs. 46.30% vs. 25.00%, respectively) than Groups B and C.
Conclusions/implications for practice:
Although the results do not provide evidence supporting the use of a 0.12% chlorhexidine oral rinse as better in terms of preventing NV-HAP in middle-aged and elderly inpatients, nursing supervision was found to have an overall positive effect on oral health. The use of oral rinse with 0.12% chlorhexidine for nonventilated patients with poor oral health may be recommended.
... Devido à intubação orotraqueal, a boca fica aberta durante todo o período, aumentando a formação da placa bacteriana e reduzindo o fluxo salivar. Jerônimo et al. (2020) concluiu que a doença periodontal tem associação significativa com a pneumonia nosocomial, já que pacientes internados com essa condição são mais propensos a desenvolverem essa infecção do que indivíduos sem periodontite.Com a impossibilidade de autocuidados, uso dos medicamentos, hipossalivação(Rabello;Araújo;Magalhães, 2018) idade do paciente e posicionamento corporal(Güler & Türk, 2019), consequentemente há uma redução do sistema de defesa inato e aumento do risco de PAVM. Portanto, é de extrema importância a criação de protocolos de higiene bucal em uma UTI. ...
... Devido à intubação orotraqueal, a boca fica aberta durante todo o período, aumentando a formação da placa bacteriana e reduzindo o fluxo salivar. Jerônimo et al. (2020) concluiu que a doença periodontal tem associação significativa com a pneumonia nosocomial, já que pacientes internados com essa condição são mais propensos a desenvolverem essa infecção do que indivíduos sem periodontite.Com a impossibilidade de autocuidados, uso dos medicamentos, hipossalivação(Rabello;Araújo;Magalhães, 2018) idade do paciente e posicionamento corporal(Güler & Türk, 2019), consequentemente há uma redução do sistema de defesa inato e aumento do risco de PAVM. Portanto, é de extrema importância a criação de protocolos de higiene bucal em uma UTI. ...
... Devido à intubação orotraqueal, a boca fica aberta durante todo o período, aumentando a formação da placa bacteriana e reduzindo o fluxo salivar. Jerônimo et al. (2020) concluiu que a doença periodontal tem associação significativa com a pneumonia nosocomial, já que pacientes internados com essa condição são mais propensos a desenvolverem essa infecção do que indivíduos sem periodontite.Com a impossibilidade de autocuidados, uso dos medicamentos, hipossalivação(Rabello;Araújo;Magalhães, 2018) idade do paciente e posicionamento corporal(Güler & Türk, 2019), consequentemente há uma redução do sistema de defesa inato e aumento do risco de PAVM. Portanto, é de extrema importância a criação de protocolos de higiene bucal em uma UTI. ...
A Odontologia Hospitalar tem ganhado campo, já que diversas experiências exitosas, associadas à evidências científicas tem demonstrado que a assistência odontológica a nível hospitalar pode contribuir para a redução dos casos de pneumonia nosocomial, associada à ventilação mecânica reduzindo assim o tempo de internação e consequentemente os custos desse processo. O objetivo desse trabalho foi verificar a eficácia dos protocolos de higienização bucal em pacientes internados em UTI, na prevenção da pneumonia associada à ventilação mecânica ou pneumonia nosocomial. Foi realizada uma revisão integrativa da literatura com buscas nas bases de dados Pubmed/MEDLINE e Scielo, na qual 23 artigos foram selecionados para a análise qualitativa após a aplicação dos critérios de elegibilidade norteados pela estratégia PRISMA. Percebe-se que o uso de Clorexidina parece ser o protocolo mais recorrente nos estudos, inclusive, com melhores resultados quando associado à adequação mecânica propiciada pela escovação, na redução dos casos de pneumonia nosocomial. Outros métodos como o uso da Iodopovidona e aspiração supraglótica foram citados, embora seus efeitos ainda sejam controversos. Dessa forma, conclui-se que apesar de não haver um protocolo bem delineado para o controle do biofilme oral e consequente redução da prevalência das pneumonias, a Clorexidina associada à escovação parece ser o método mais promissor. Mais estudos com metodologias robustas são necessários para a compreensão e propostas de protocolos baseados em evidências científicas para higienização oral de pacientes em terapia intensiva, com foco em reduzir a morbimortalidade por pneumonia nosocomial.
... It is better to use a toothbrush rather than a cotton swab for teeth, and the use of toothpaste is effective [50]. Several previous studies have suggested that brushing with a manual toothbrush and rinsing with CHX are the most commonly recommended measures for oral care in ICU patients [50,51]. However, it is often reported that uniform oral hygiene management guidelines are not implemented, even in the same institution. ...
... Several systematic reviews and meta-analyses have been conducted on the appropriate concentration and usage of CHX. Rabello et al. demonstrated that various CHX regimens and doses (0.12-2%) were effective in preventing nosocomial pneumonia and VAP in ICU patients [51]. In 2014, Zhang et al. compared the effects of various concentrations of CHX and concluded that 0.12% CHX was the best option with respect to cost, adverse reactions, drug resistance, and VAP prevention [53]. ...
... Many studies have shown the effectiveness of oral hygiene management, including the application of CHX, for respiratory disease prevention in ICU patients [6,11,21,41,47,48,51,53,54,56,60,61,[67][68][69][70][71][72][73][74][75][76]. In 2013, Hillier et al. reported that the education of nurses on oral care, including CHX application and other oral care methods, reduced the incidence of VAP [3]. ...
This study aimed to review the oral hygiene status, oral care guidelines, and outcomes of oral care in intensive care unit (ICU) patients from a dental perspective for effective oral care. A literature search using the keywords “Hospital dentistry” OR “Oral care” OR “Intensive care unit” OR “Hospital inpatient” OR “Hospitalization” OR “Emergency service” AND “Oral health” OR “Oral hygiene” OR “Dental plaque” was conducted in PubMed, Medline, and Google Scholar to identify publications reporting on the oral care of the patients admitted to ICUs. A total of 17,400 articles were initially identified. Of these, 58 were selected and classified into three categories for critical review. Seven of these studies evaluated the oral status of ICU patients, and most of the studies indicated that ICU patients had poor oral hygiene or required active dental treatment. Thirty-three of these studies evaluated oral care methods for ICU patients, and in general, oral care methods using chlorhexidine as adjuncts along with tooth brushing were recommended. However, there were insufficient studies to evaluate oral hygiene through effective assessment tools from a dental perspective. In 36 studies on the outcomes of oral care in ICU patients, interventions by dental professionals showed effective results in preventing hospital-acquired infection. This review highlights the importance of establishing guidelines for the evaluation of oral status in ICU patients and summarizes data that may be useful for future studies. Further studies on maintaining good oral hygiene among ICU patients are needed.
... For this reason, mechanically-ventilated patients in ICUs have significantly low mortality rates when oral hygiene is performed with a chlorhexidine solution (Klompas, 2019). However, it is suggested that the retention time of this substance in the oral cavity of mechanically-ventilated in patients may differ due to several factors inherent to these patients' critical condition (Rabello et al., 2018). Given the relevance of this topic, the critical condition of ICU patients is a challenge for health professions, for which reason it is important to use evidence-based protocols focused on preventive strategies. ...
... After 12 hours, the number of microorganisms decreased by 12% and 58% in both groups, respectively. Chlorhexidine is widely used for reducing the number of microorganisms in the oral cavity, and several studies have reported its influence on the prevention of VAP in hospitalized patients (Camargo et al., 2019;Deschepper et al., 2018;Meidani et al., 2018;Rabello et al., 2018;Vidal et al., 2017;Zand et al., 2017). In this context, the time necessary for microbial reduction after oral hygiene with a 0.12% chlorhexidine solution is still unclear, especially in patients with an orotracheal tube. ...
... In this context, the time necessary for microbial reduction after oral hygiene with a 0.12% chlorhexidine solution is still unclear, especially in patients with an orotracheal tube. Variations in studies with different populations, concentrations, chlorhexidine preparations, and hygiene frequency make it difficult to compare different findings (Galhardo et al., 2020;McCue & Palmer, 2019;Rabello et al., 2018;Zand et al., 2017). Studies show that chlorhexidine did not reduce the total number of bacteria in the oral cavity after oral hygiene in mechanically-ventilated patients (Vidal et al., 2017;Scannapieco et al., 2009). ...
Enquadramento:
O controlo do biofilme oral com anti-sépticos deve ser adequado aos protocolos elaborados para os doentes na unidade de terapia intensiva (UTI).
Objetivo:
Avaliar o efeito da solução de clorexidina 0,12% na redução de microrganismos na saliva de doentes de UTI.
Metodologia:
Estudo coorte com 45 voluntários divididos em: Clínica Médica (controlo, auto higiene oral), UTI não-entubado e UTI entubado. A higiene oral na UTI foi realizada com clorexidina. A análise microbiológica foi realizada com a contagem de microrganismos na saliva. A análise dos dados foi feita com ANOVA.
Resultados:
Houve uma redução dos microrganismos após higiene oral. O controlo apresentou diferença significativa com UTI entubado nos períodos imediato e após 30 min. Doentes entubados apresentaram redução dos microrganismos até 12 horas após higiene com clorexidina.
Conclusão:
A higiene com clorexidina reduz em até 12 horas os microrganismos bucais de doentes entubados. Estes resultados podem contribuir para elaboração de protocolos de higiene oral em UTI, além de sustentar estratégias como redução nos custos e efeitos colaterais associados à clorexidina.
... 4,9,15 Thus, it is necessary formalizing effective protocols focused on oral health research, professional training and on the education of, and direct communication with, other health professionals about dental care in ICUs, besides standardizing preventive behaviors, providing health education and developing better elaborated protocols. 6,[16][17][18][19][20] The aim of the current study was to assess the prevalence of tongue coating in patients treated in the intensive care unit of a hospital in Federal District, Brasília, Brazil. ...
... ICUs are the places where such aspiration processes can be more often observed, given the possible changes in patients' consciousness levels and the lack of specific hygiene activities. 9, 14,16,26 The 48-to-72-hour period after ICU admission is critical because it directly affects bacterial pathogenicity, in which gram-negative bacteria prevail. Based on our results, 69 patients (p < 0.001) remained in the ICU for 48 hours (two days), whereas more than 85 patients recorded critical ICU length of stay (48 to 72 hours). ...
... Therefore, it is necessary taking educational measures to teach health professionals working in hospitals to perform specific dental care procedures under proper supervision. 2,6,7,16,18,22 Controlling the dental biofilm and tongue coating in ICU patients through the association between mechanical and chemical strategies is the best way to promote their oral health. Strategies such as toothbrushing in the posteroanterior direction with a toothbrush imbibed in 0.1% chlorhexidine solution, applying gauze imbibed in 0.12% chlorhexidine attached to a needle holder (movements towards the posteroanterior direction) and using wooden spatulas and tongue cleaners with saline solution can be adopted to disorganize and remove tongue coating in all patients (tracheostomized, intubated and normal condition). ...
Objetivo: avaliar a incidência de saburra lingual em pacientes atendidos em unidade de terapia intensiva (UTI) de um hospital do Distrito Federal, Brasil. Material e Métodos: estudo descritivo e prospectivo com coorte de conveniência aprovado pelo Comitê de Ética em Pesquisa. Um único examinador conduziu exames clínicos com foco na avaliação da incidência de saburra lingual em pacientes internados em UTI por cinco semanas, às vezes programadas pelo conselho de administração da UTI. Os dados foram registrados em uma folha de dados padronizada. Resultados: foram avaliados 152 pacientes do sexo masculino e feminino (57% mulheres e 42% homens), com idade média de 64 anos. Os pacientes foram internados na UTI, principalmente sob condições normais (p <0,001); o período mais longo na UTI foi de 48 horas (p <0,001). A maioria dos pacientes (56) apresentou revestimento em suas línguas (p <0,001). Associações entre o tempo de internação hospitalar e a incidência de saburra lingual não foram estatisticamente significantes. Conclusão: a incidência de saburra lingual permanece alta nos pacientes tratados na UTI investigada. Assim, faz-se necessário o desenvolvimento de estratégias educativas e clínicas, bem como a implementação de protocolos de capacitação específica e profissional.
... 1. Обработка полости рта водным раствором хлогексидина [33]. Обработка полости рта антисептиками была выбрана в качестве профилактики НП исходя из представлений о патогенезе НП -микроаспирация содержимого ротовой полости. ...
... По данным последнего метаанализа [33], эффективность данной методики была доказана исключительно в категории кардиохирургических пациентов, которые находятся на ИВЛ не более 24 ч. Также необходимо принимать во внимание методологические аспекты исследований по эффективности хлоргексидина в профилактике НП: обработка полости рта хлоргексидином (антисептик) неизбежно снижает частоту положительных культур мокроты [34]. ...
Nosocomial pneumonia and nosocomial tracheobronchitis present an urgent problem of anesthesiology and critical care medicine. This review presents the results of our own research on the informativity of new molecular biomarkers in the early diagnosis of nosocomial pneumonia, as well as modern principles for the prevention of nosocomial pneumonia. A promising direction for the early diagnosis of nosocomial pneumonia and its complications is the study of new molecular biomarkers, in particular, Clara cell protein and surfactant proteins. Effective prevention of nosocomial pneumonia should be based on a complex of modern evidence-based methods.
... U znanstvenim pregledima i studijama zagovara se sinergijska primjena kemijskih i mehaničkih metoda čišćenja kao strateška mjera za smanjenje stopa bolničkih infekcija, te se ističe integralna uloga dentalnih profesionalaca u oblikovanju strategija oralne njege za kontekste JIL-a (9, 30, 58, 64 -75). Promatrana heteroge-sing methodologies as a strategic measure to slash hospital infection rates, spotlighting the integral role dental professionals play in sculpting oral care stratagems for ICU contexts (9,30,58,(64)(65)(66)(67)(68)(69)(70)(71)(72)(73)(74)(75). The observed heterogeneity in oral care practices underscores an acute need for the establishment of uniform protocols aimed at amplifying the effectiveness of these regimens in curtailing pathogen proliferation and reducing the incidence of pneumonia (11,15,17,60). ...
Objective
This study assesses the knowledge, practices, and attitudes of medical staff in intensive care units (ICUs) regarding oral hygiene care for critically ill, bedridden patients.
Material and methods
A cross-sectional study included 65 employees from the Intensive Care Units of the Sestre Milosrdnice Clinical Hospital Centre (CHC SM) and the Clinic for Anesthesiology and Intensive Care at the University Clinical Hospital Centre Zagreb (CHC ZG). A self-administered questionnaire was used to assess knowledge, methods, frequency, and attitudes towards oral care for mechanically ventilated patients. The data were examined through descriptive statistical methods, presented in terms of proportions (percentages). For the purpose of comparing the feedback across the two hospital centers and different educational backgrounds, the Chi-square and Fisher's exact tests were employed.
Results
Results of a survey of 65 participants (18 from CHC SM and 47 from CHC ZG) revealed a notable disparity in oral hygiene knowledge, with graduate nurses displaying the highest proportion of adequate knowledge (100%) and regular nurses showing the least (30.3%) (p<.001). Although the execution of oral care practices did not vary significantly among the groups, graduate nurses performed oral care more frequently (80% vs. baccalaureate technicians 33.33% and nurses 57.6%, three or more times a day) and demonstrated better proficiency in both mechanical (p=.005) and chemical (p<.001) biofilm management compared to their counterparts. No significant difference was observed in the delivery of oral care to orotracheally intubated patients across different educational levels (p=.127). However, a marked difference was noted in the perception of being adequately trained for such care, with nurses feeling less prepared (12.1%, p<.001). Despite these variances, all respondents recognized the importance of oral hygiene, thus showing a strong dedication to oral health care. Conclusions: This study highlights variability in ICU oral hygiene practices and points to the importance of standardized care protocols and improved training for healthcare staff.
... 6 However, a recent systematic review by Klompas et al. 11 revealed no significant difference in ventilator-associated pneumonia risk in double-blind studies of non-cardiac surgery patients. Rabello et al. 12 also showed inconsistency in a recent overview evaluating 14 systematic reviews and meta-analyses with high-quality evidence. The authors showed that CHX effectively prevented nosocomial pneumonia among adults in cardiothoracic ICU but not in other clinical-surgical units. ...
... But, in those with a varied clinical-surgical conditions, the effectiveness of CHX for the prevention respiratory infection was inconclusive. 22 It is assumed that the use of scientific-based oral hygiene protocol may allow a better dental biofilm control and reduction in hospitalized patients, to maintain and improve oral health conditions. 12,23,24 Thus, this study aimed to verify the effectiveness of a new standardize oral hygiene protocol (NEWPROT) in reducing postsurgical infections, applied prior to cardiac surgery, when compared to usual oral hygiene practices performed by hospitalized patients and the nursing team-not standardize protocol (NOTPROT)-in a cardiology unit. ...
Context:
It is not clear if an oral hygiene protocol to control biofilm applied before cardiac surgery can reduce infection rates.
Objective:
We aim to verify the effectiveness of an oral hygiene protocol in reducing postoperative infections when compared to usual practices, in patients admitted to a cardiology unit, prior to cardiac surgery.
Design, setting, and participants:
Randomized, blind, controlled clinical trial, with 107 participants who expected to undergo cardiac surgery, randomized into two groups: Experimental Group (EG) standardized oral hygiene protocol (54) and Control Group (CG), usual practices performed in patients admitted (53).
Intervention:
a standardized oral hygiene protocol, one day before surgery: professional prophylaxis with a portable ultrasound device, tooth brushing, and flossing plus a 0.12% chlorhexidine gluconate solution (0.12% CHX) mouth rinsing. When applicable, removable prostheses cleaning.
Primary outcome:
the presence of infection.
Results:
The occurrence of postoperative infection was higher in CG = 7 (13.2%) than in EG = 5 (9.3%); but no statistical difference was found between protocols (p=0.518). The length of stayed from surgery to discharge presented a statistical difference (p=0.047;RR=4.9;CI=1.01-24.33); the percentage of postoperative infection was almost five times higher in those participants who stayed 11 or more days.
Conclusion:
The standardized oral hygiene protocol with mechanical and chemical cleaning, one day before cardiac surgery, was not more effective than the usual practices performed regarding the reduction of postoperative infections. Other interventions regarding oral hygiene procedures before cardiac surgery must be studied to contribute to the reduction of adverse post-surgical events.
... Severe pneumonia has an acute onset and rapid progress and is often accompanied by varying degrees of respiratory failure, septic shock, and decreased blood pressure. Excitation of the sympathetic adrenal concomitant system results in decreased intestinal perfusion pressure and vasoconstriction of the intestinal mucosa, which then leads to ischemia and hypoxia of intestinal mucosal tissues [7,8]. ...
Objective:
This study examines the effects of the 3S2E nursing management mode on patients with severe pneumonia in the intensive care unit's respiratory function, psychological status, and quality of life (ICU).
Methods:
According to a random number table, 82 ICU patients with severe pneumonia who were admitted between March 2021 and March 2022 were enrolled and assigned to the control and observation class (n = 41, respectively) in a 1 : 1 ratio. The observation class added 3S2E manner in addition to ordinary breastfeeding, whereas the control class received treatment in the usual nursing mode. The two groups' preintervention and postintervention times for mechanical ventilation, white blood cell count (WBC) recovery, duration of hospital stay, problems, respiratory function, psychological state, and living quality were compared.
Results:
Fever time abatement, mechanical ventilation time, WBC recovery time, and length of hospital stay in the observation category were found to be shorter in comparison with the control class (P < 0.05). In contrast to the other group, the observation group had fewer issues (P < 0.05). Both teams' oxygenation indices and SaO2 were higher after the intervention (P < 0.05), with the observation team's index being higher than the control group's index. The total SAS and SDS scores of the two groups were less in the postintervention period than in the preintervention period, with the observational class having lower postintervention SAS and SDS ratings than the comparison group (P < 0.05). The postintervention ratings in the observation class were higher than those in the control, and the World Health Organization Quality of Life (WHOQOL) scale scores in the 2 categories were greater after the intervention than they were before (P < 0.05).
Conclusion:
3S2E nursing management model improves respiratory function, alleviates negative emotions, and improves living quality in ICU patients with severe pneumonia.
... There is an imbalance of the microbiota and a consequent increase in the colonization of the biofilm and respiratory pathogens in the oral cavity. Therefore, oral hygiene care should reduce oropharyngeal colonization and dental biofilm, which may be responsible for the occurrence of other infections (Rabello et al., 2018). The use of 0.12% chlorhexidine is recommended for oral hygiene of patients admitted to the ICU and its antiseptic potential reduces bacteria and prevents local and systemic infections (Woolum et al., 2019). ...
Toxic epidermal necrolysis (TEN) is a mucocutaneous disorder characterized by the detachment of epidermal and mucous tissues and areas of necrosis, resulting from hypersensitivity reactions to different drugs. We report a clinical case of a 19-year-old male patient diagnosed with TEN, with 90% involvement of the body surface and severe oral involvement. The patient was monitored by dentists from the multidisciplinary team of an intensive care unit, where adjuvant treatment was performed through photobiomodulation to control pain and regenerate the oral mucosa. The case represents the importance of early performance in oral TEN injuries and the role of the multidisciplinary team for comprehensive treatment.
... Portanto, torna-se imprescindível que os profissionais envolvidos no manejo dos pacientes internados em UTI tenham conhecimento para promover a manutenção da saúde bucal deles, já que tais pacientes geralmente se encontram impossibilitados de realizar o autocuidado e apresentam higiene bucal inadequada ao longo da internação [12,17,18]. Desse modo, esta pesquisa teve o objetivo de verificar a percepção dos profissionais de enfermagem sobre a saúde bucal, suas práticas de higienização e dificuldades em promover o cuidado bucal a pacientes em duas UTIs. ...
A unidade de terapia intensiva (UTI) é um setor hospitalar em que se presta assistência a pacientes com necessidade de cuidados intensivos. Nesse cenário, a equipe de enfermagem assume importância no cuidado aos pacientes internados e é a responsável pelo cuidado bucal em alguns hospitais. Esses pacientes possuem alterações bucais, e os profissionais envolvidos devem ter conhecimento para promover a manutenção da saúde bucal deles. Objetivo: Verificar a percepção dos profissionais de enfermagem sobre a saúde bucal e suas práticas de higienização em duas UTIs. Material e métodos: Trata-se de um estudo descritivo e seccional em duas UTIs (uma pública e uma privada). A amostra foi constituída dos profissionais de enfermagem ativos, os quais responderam a um questionário validado. Os dados obtidos foram submetidos à análise estatística descritiva. Resultados: A média de idade dos entrevistados no hospital público e no hospital da rede privada, respectivamente, foi de 34 e de 37 anos, com tempo de atuação profissional de 9 e de 12 anos, em sua maioria do sexo feminino (56,1 e 78%) e técnicos em enfermagem (90 e 86%). Em relação ao cuidado bucal, 44 e 30% dos profissionais o realizam apenas uma vez ao dia, 63 e 62% não souberam definir biofilme dentário, e 40 e 46,2% disseram que mais treinamentos seriam necessários. Além disso, a utilização da clorexidina (0,12%) era realizada por 100% dos entrevistados no hospital público e 80% no hospital particular, mais frequente do que a remoção mecânica do biofilme. Conclusão: Há deficiências no conhecimento da saúde bucal dos pacientes, o que reforça a importância da educação continuada dos profissionais de enfermagem, além da presença do cirurgião-dentista.
... 13,14 Accordingly, a large retrospective observational study on 82 274 patients in a hospital in Belgium showed a significant association between nonintubated patients and mortality when exposed to oral care with CHX. 15 However, cardiothoracic patients seems to be the only population showing evidence of effectiveness in preventing VAP when oral care is performed with CHX mouthwashes. 16 On these bases, the Intensive Care Society did no longer recommend the use of CHX oral mouthwashes (with the exception of cardiosurgical patients) and removed it from its VAP Bundle, whereas it has maintained the following interventions: elevation of head of bed (30°-45°), daily sedation interruption and assessment of readiness to extubate, use of subglottic secretion drainage, and avoidance of scheduled ventilator circuit changes. 17 While we are writing these few lines, a large multicentric RCT on 3260 patients from 6 Canadian ICUs has been published, aiming to reveal the effects on patients' mortality rates of de-adoption of oral CHX and the implementation of an oral care bundle. ...
... A 0.12% chlorhexidine protocol every 12 hours has been shown to be extremely effective in preventing nosocomial pneumonia. 9 A study by Araújo et al., 10 compared the periodontal condition of patients admitted to intensive care units and patients not admitted to intensive care units. Additionally, a quantitative microbiological analysis of the subgingival biofilm was performed. ...
... A subcategory of HAP is ventilatorassociated pneumonia (VAP), which is defined as pneumonia that develops 48 hours or longer after mechanical ventilation is given by means of an endotracheal tube or tracheostomy (Rabello et al, 2018). ...
... A utilização do digluconato de clorexidina 0,12% é o protocolo internacional de higienização bucal adotado na maioria das unidades de terapia intensiva, pois apresenta ação bactericida e bacteriostática, além de contribuir no controle inflamatório presente na cavidade bucal. É importante ressaltar a correta utilização e frequência de uso nos pacientes hospitalizados 8,10,13,15,16,22,27,30,37,46,50,65,67,69,73,76,79,82,87,91,[94][95][96] . Intervenções cirúrgicas, profiláticas (escovação dentária -ação mecânica) e de caráter periodontal (raspagens sub e supragengival) podem ser realizadas com a finalidade preventiva e emergencial no ambiente hospitalar -UTI, principalmente àquelas em que os elementos dentários passam a ser possíveis focos infecciosos, inflamatórios e de sintomatologia dolorosa, sendo consideradas como desencadeadores negativos da recuperação dos pacientes e de direta interferência sistêmica 1,11,23,[26][27][28]84,93,97 . ...
... A utilização do digluconato de clorexidina 0,12% é o protocolo internacional de higienização bucal adotado na maioria das unidades de terapia intensiva, pois apresenta ação bactericida e bacteriostática, além de contribuir no controle inflamatório presente na cavidade bucal. É importante ressaltar a correta utilização e frequência de uso nos pacientes hospitalizados 8,10,13,15,16,22,27,30,37,46,50,65,67,69,73,76,79,82,87,91,[94][95][96] . ...
... A previous meta-analysis shows that oral care with chlorhexidine might be effective in reducing VAP incidence in the adult population when administered at 2% concentration or 4 times/day (Villar et al., 2016). However, Rabello et al. (2018) suggests that administration of chlorhexidine for the prevention of VAP was inconclusive, so further studies are needed to confirm the role of intraoral chlorhexidine in the management of VAP. ...
Ventilator-associated pneumonia (VAP) is one of the most prevalent and serious complications of mechanical ventilation, which is considered a common nosocomial infection in critically ill patients. There are some great options for the prevention of VAP: (i) minimize ventilator exposure; (ii) intensive oral care; (iii) aspiration of subglottic secretions; (iv) maintain optimal positioning and encourage mobility; and (v) prophylactic probiotics. Furthermore, clinical management of VAP depends on appropriate antimicrobial therapy, which needs to be selected based on individual patient factors, such as previous antibacterial therapy, history of hospitalization or mechanical ventilation, and bacterial pathogens and antibiotic resistance patterns. In fact, antibiotic resistance has exponentially increased over the last decade, and the isolation of a multidrug-resistant (MDR) pathogen has been identified as an independent predictor of inadequate initial antibiotic therapy and which is significantly associated with increased mortality. Multiple attempts were used in the treatment of VAP, such as novel antibacterial agents, inhaled antibiotics and monoclonal antibodies. In this review, we summarize the current therapeutic options for the prevention and treatment of VAP, aiming to better management of VAP in clinical practice.
O cirurgião-dentista tem um papel fundamental no ambiente hospitalar para a promoção da higiene bucal. Sabe-se que a cavidade bucal é um meio de contaminação, e as bactérias e microrganismos podem ser aspirados e alojarem em regiões do corpo, como os pulmões. Tais alterações sistêmicas podem comprometer o sistema imunológico do indivíduo, contribuindo para períodos maiores de internação, tanto pelo retardo do processo de cura, quanto pela existência de doenças associadas às comorbidades que levaram a internação. O uso de próteses bucais, principalmente nos Centros de Terapia Intensiva – CTI, podem contribuir para tais situações indesejadas. Por este motivo, este trabalho objetivou desenvolver um protocolo de higienização e guarda de próteses dentárias na Santa Casa de Caridade de Diamantina-MG. Para a realização deste protocolo, utilizou-se de uma revisão narrativa da literatura nas bases de dados (Pubmed/Medline, Scielo, Bireme, Google Acadêmico, Embase e Cochran) com os descritores relacionados à odontologia hospitalar tanto em português como no idioma inglês: higiene de próteses dentárias, protocolos de higiene de próteses, protocolos armazenamento das próteses, saúde bucal de idosos hospitalizados, além de evidências científicas sobre cuidados à saúde bucal de idosos no ambiente hospitalar. O protocolo foi desenvolvido com base na literatura encontrada e apresentado para a Equipe de Enfermagem, totalizando 45 membros, com a perspectiva de implementação do mesmo. A criação de protocolos para ambientes hospitalares representa uma estratégia eficaz na prevenção de infecções sistêmicas. As condutas específicas direcionando e informando os profissionais para a saúde bucal leva a equipe de saúde a promover uma adequação do meio bucal e consequentemente melhoria na saúde do paciente durante a sua internação, minimizando as infecções hospitalares.
Introduction: Nosocomial infections such as surgical site infections (SSI) and postoperative pneumonia significantly contribute to a patient’s morbidity and mortality. This systematic review and meta-analysis evaluate the effectiveness of oral hygiene programs in reducing the incidence of nosocomial infections and related postoperative complications among all surgical patients. Methods: The systematic review and meta-analysis were conducted in line with the Cochrane Handbook for Systematic Reviews of Interventions. Medline and the Cochrane controlled trials (CENTRAL) databases were searched. Two review authors independently selected the trials and extracted the outcome data. The risk of bias of each included study was assessed independently by two review authors using the tool recommended in the Cochrane Handbook for Systematic Reviews of Interventions. Meta-analysis was performed when more than one trial reported the same outcome for the same comparison. Results: 29 systematic reviews and 59 randomized controlled trials were included in the review. Thirty-two trials compared chlorhexidine with placebo, 7 trials povidone iodine with placebo, 7 trials topical antibiotics with placebo, 1 trial essential oils with placebo, 3 trials other agents with placebo, and 5 trials toothbrushing with no toothbrushing. Five trials compared one agent with another agent, and 1 trial compared dosings and frequencies of chlorhexidine use. Chlorhexidine was associated with a reduced risk of nosocomial infection, nosocomial pneumonia, ventilator-associated pneumonia (VAP), and shorter hosptial stay, and no significant impact on surgical site infection rates, ventilator days and mortality. Povidone iodine did not show any significant benefit on reducing VAP rates, ventilator days, ICU days, or mortality when compared against placebo. Hexetidine,when compared with placebo showed similar incidences of VAP. Topical oral antibiotics did not provide significant reduction on VAP rates, ventilator days, ICU days and mortality rates, compared with placebo. Conclusion: Oral hygiene offers benefits in terms of lower rates of nosocomial infection, nosocomial pneumonia, ventilator-associated pneumonia, surgical site infection, shorter ICU stay, less ventilator days and lower oral colonization / colony counts. Key words: Oral Hygene
Background:
Poor oral health is associated with adverse outcomes in critical care settings. Although provision of oral care is a fundamental aspect of nursing practice, both formal training and practice among nursing staff remain unclear.
Method:
Cardiothoracic intensive care unit nurses were recruited to complete a 16-item survey regarding training, confidence, methods, prioritization, and barriers to provision of oral care.
Results:
A total of 108 nurses participated (70% response rate). Formal training in oral care was reported by 38%, most frequently reported as less than 1 hour (53%) in duration. Of the respondents, 70% reported confidence in providing oral care. Nine methods and 16 products were identified, with variability in the frequency of provision. Prioritization of oral care was rated most frequently as moderate (53%), with 28% reporting barriers.
Conclusion:
Despite limited formal training, surveyed nurses reported confidence in providing oral care. Methods, frequency, and prioritization were variable. Both development of formal curricula and evaluation of adherence to standardized protocols for oral care are warranted. [J Contin Educ Nurs. 2023;54(7):313-321.].
A odontologia hospitalar tem alcançado patamares de grande importância no atendimento a pacientes hospitalizados, principalmente naqueles que permanecem por longos períodos em unidades de terapia intensiva. Com o avanço dos estudos e observações, nota-se que um cuidado ideal da saúde bucal tem demonstrado bons resultados, principalmente no que tange as complicações oportunistas, como por exemplo nos casos de doenças infecciosas que se originam na cavidade bucal, como a pneumonia nosocomial. O objetivo do presente trabalho foi analisar a importância do papel do cirurgião-dentista dentro de uma unidade de terapia intensiva, com o intuito de avaliar os riscos relacionados às infecções de ordem bucal, descrever o atendimento odontológico de pacientes críticos e relatar os possíveis problemas bucais encontrados nesses pacientes. Observou-se que o cuidado com a saúde bucal do paciente internando em UTI vêm se mostrando cada vez mais necessário. A equipe de enfermagem que atua dentro desse serviço não possui o preparo e o conhecimento para cuidar desses pacientes, sendo muito importante a integração do profissional cirurgião dentista na atenção integral ao paciente hospitalizado. Concluiu-se que a atuação do cirurgião dentista nas unidades de terapia intensiva é importante para a manutenção da saúde bucal dos pacientes críticos, repercutindo de forma positiva na saúde sistêmica, ao prevenir a colonização da cavidade oral por microorganismos patogênicos e reduzir a incidência de infecções como a pneumonia associada a ventilação mecânica.
Objective
This study aimed to investigate chlorhexidine’s efficacy in preventing ventilator-associated pneumonia (VAP).
Design
A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Settings
The data were obtained from Pubmed, Cochrane Library, and EMBASE.
Patients or participants
Only mechanically ventilated patients for at least 48 h were included.
Interventions
Randomized clinical trials applying any dosage form of chlorhexidine were eligible.
Main variables of interest
The relative risk (RR) of the VAP incidence and all-cause mortality was assessed using the random-effects model. The mean difference in days of mechanical ventilation duration and intensive care unit (ICU) length of stay were also appraised.
Results
Ten studies involving 1233 patients were included in the meta-analysis. The oral application of CHX reduced the incidence of VAP (RR, 0.73 [95% CI, 0.55, 0.97]) and did not show an increase in all-cause mortality (RR, 1.13 [95% CI, 0.96, 1.32]).
Conclusions
CHX proved effective to prevent VAP. However, a conclusion on mortality rates could not be drawn because the quality of the evidence was very low for this outcome.
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.
Ventilator-associated pneumonia (VAP) is related with high mortality, duration of mechanical ventilation and costs. Recent studies have questioned the safety and effectiveness of oral chlorhexidine to prevent VAP. We sought to verify whether the adverse effects of this substance outweigh its benefits. We searched several databases and selected studies that investigated the use of oral chlorhexidine and its impact on mortality. No association between oral chlorhexidine and lower VAP rates was found on meta-analyses of double-blind randomized trials, however significant increase in mortality was reported. It is speculated that chlorhexidine can cause damage to several organic sectors and cytotoxicity. Although it still can be beneficial in specific settings, robust evidence to recommend its routine application for all mechanically ventilated patients is lacking; therefore, given the possibility of harm, it would be better to follow the principle of non-maleficence until more studies becomes available.
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.
Ventilator-associated pneumonia (VAP) is related with high mortality, duration of mechanical ventilation and costs. Recent studies have questioned the safety and effectiveness of oral chlorhexidine to prevent VAP. We sought to verify whether the adverse effects of this substance outweigh its benefits. We searched several databases and selected studies that investigated the use of oral chlorhexidine and its impact on mortality. No association between oral chlorhexidine and lower VAP rates was found on meta-analyses of double-blind randomized trials, however significant increase in mortality was reported. It is speculated that chlorhexidine can cause damage to several organic sectors and cytotoxicity. Although it still can be beneficial in specific settings, robust evidence to recommend its routine application for all mechanically ventilated patients is lacking; therefore, given the possibility of harm, it would be better to follow the principle of non-maleficence until more studies becomes available.
Nosocomial pneumonia and nosocomial tracheobronchitis present a significant problem of anesthesiology and critical care medicine. This review presents the results of our own research on the usefulness of new molecular biomarkers in the early diagnosis of nosocomial pneumonia, as well as modern principles for its prevention. A promising direction for the early diagnosis of nosocomial pneumonia and its complications is the study of new molecular biomarkers, in particular, Club cell protein and surfactant proteins. Effective prevention of nosocomial pneumonia should be based on a complex of modern evidence-based methods.
Objective:
The aim of this systematic review (SR) was to assess whether toothbrushing-based oral heath measure (OHM), performed in intensive care units, can reduce the risk of ventilator-associated pneumonia (VAP).
Background:
Dental biofilm removal has been considered important to prevent VAP.
Methods:
PUBMED, SCOPUS, WEB OF SCIENCE and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched up to and including December 2018 to identify randomized clinical trials (RCT) on the use of toothbrushing procedures in the prevention of VAP. Search was conducted by two independent reviewers. The risk of bias of each included study was assessed using the Cochrane Collaboration's domain-based, two-part tool. Random effects meta-analyses were conducted thoroughly.
Results:
Search strategy identified 215 potentially eligible articles, of which 12 RCT were included. All studies evidenced the importance of OHM in mechanically ventilated patients in order to prevent VAP. Seven RCT (58.3%) found some degree of positive association between toothbrushing, alone or associated to oral topical chlorhexidine (CHX), and a potential reduction of mechanical ventilation-related outcomes and dental biofilm/oral bacteria. However, pooled estimates did not identify an additional decrease of VAP incidence for any of the tested procedures (ie, toothbrushing + CHX versus swab/gauze cleaning + CHX or toothbrushing + CHX versus toothbrushing alone or + placebo).
Conclusions:
Toothbrushing does not seem to promote a reduction of VAP-outcomes compared to swab/gauze cleaning, when topic CHX is applied for oral hygiene of patients submitted to mechanical ventilation.
Ventilator associated pneumonia (VAP) is common problem among mechanically ventilated patients. However improvements in oral hygiene in these patients may prevent ventilator-associated pneumonia. The goal of this study was to determine the efficacy of 0.12% chlorhexidine gluconate mouth care to prevent the VAP among mechanically patients admitted in ICUs. A randomized control trial was carried out on 260 patients, where equal number of patients randomized in experimental (130 patients) and control group (130 subjects). Study was conducted during August to December 2010 to assess the efficacy of 0.12% chlorhexidine gluconate mouth care in prevention of VAP among mechanically ventilated patients. Study found that mouth care with 0.12% chlorhexidine twice daily was significantly effective in prevention of VAP among mechanically ventilated patients as compared to conventional method of mouth care (VAP: 5.7% vs. 35.4%) without any significant adverse event (p<0.05). Furthermore, it found that increased duration of mechanical ventilation escalates the risk of VAP; however, chlorhexidine mouth care was consistently effective with even longer duration of mechanical ventilation. Mouth care twice daily with 0.12% chlorhexidine is significantly effective in prevention of VAP among mechanically ventilated patients. Therefore, it is recommended to provide mouth care twice daily with 0.12% chlorhexidine to mechanically ventilated patients for prevention of VAP.
Purpose. The aim of this review was to evaluate the evidence on the effectiveness of oral chlorhexidine in the prevention of ventilator-associated pneumonia (VAP) in critically ill adult mechanically ventilated patients in intensive care units (ICUs). Methodology. An extensive literature search of studies published in English was undertaken between June 2010 and June 2011. Electronic databases searched were the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index of Nursing and Allied Health (CINAHL) and MEDLINE. Reference lists of articles, textbooks and conference summaries were examined and hand searching was performed. Literature searches were done using the following Medical Subject Headings (MeSH) terms: ventilator-associated pneumonia, VAP, chlorhexidine, hospital-acquired pneumonia, nosocomial infections, mechanically ventilated patients, intensive care, mouthwash, mouth care, oral care, oral hygiene and dental care. Selection criteria. Two reviewers selected the studies independently. Eight randomised controlled trials investigating the efficacy of oral chlorhexidine versus power tooth brushing, Listerine, placebos, bicarbonate isotonic serum rinse and normal saline in the prevention of VAP in adult mechanically ventilated, critically ill patients in ICUs met the inclusion criteria. Data collection and analysis. All relevant data were entered into Review Manager (version 5.1) for analyses. The effect measure of choice was the risk ratio (RR) with 95% confidence intervals (CIs) for dichotomous data using the random effects (Mantel-Haenszel) model (p-value 0.05). Heterogeneity was assessed using the Cochrane Q statistic and I2. Results. Eight randomised controlled trials met the inclusion criteria for this review. There was a 36% higher chance of VAP in the control group compared with the chlorexidine group (RR 0.64, 95% CI 0.44-0.91). The variation between the included studies was very small (χ2=0.24). Conclusion. Treatment with chlorhexidine decreased the risk of VAP by 36%. The use of 2% chlorhexidine may be most effective in reducing the incidence of VAP. There was no evidence of an effect of chlorhexidine on mortality.
Background/purpose
Ventilator-associated pneumonia (VAP) is one of the most frequent causes of morbidity and mortality among mechanically ventilated patients in critical care. Previous meta-analyses demonstrated that oral chlorhexidine (CHX) is beneficial in preventing VAP. Several new studies on oral hygiene as a preventive measure for VAP have been published. Considering all the currently available evidence together, an updated meta-analysis was conducted to evaluate the efficacy of oral CHX in preventing VAP.
Materials and methods
A comprehensive literature search was conducted to identify clinical trials comparing oral hygiene care using CHX with conventional care in terms of the incidence of VAP. Two reviewers independently assessed each report to confirm that all reports met the inclusion criteria. The data from each trial were combined using the Mantel–Haenszel fixed-effects model to calculate the pooled relative risk and the corresponding 95% confidence intervals. Funnel plots were used to assess publication bias.
Results
Nine randomized controlled trials met our inclusion criteria. Overall, 1623 patients received oral hygiene with CHX and 1662 received a placebo. The heterogeneity of the data was statistically refuted. Oral hygiene using CHX resulted in a reduced incidence of VAP (relative risk = 0.59; 95% confidence interval, 0.47–0.73; P < 0.001; I2 = 27.8%) according to a fixed-effects model. Publication bias was not apparent in the funnel plots.
Conclusion
The analysis showed that oral CHX decontamination significantly reduced the incidence of VAP but not the mortality rate.
Objective
Nosocomial or more exactly, hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) are frequent conditions when treating intensive care unit (ICU) patients that are only exceeded by central line-associated bloodstream infections. In Germany, approximately 18,900 patients per year suffer from a VAP and another 4,200 from HAP. We therefore reviewed the current guidelines about HAP and VAP, from different sources, regarding the strategies to address individual patient risks and medication strategies for initial intravenous antibiotic treatment (IIAT).
Material and methods
We conducted an analysis of the recent guidelines for the treatment of HAP. The current guidelines of the American Thoracic Society, the treatment recommendations of the Paul-Ehrlich-Gesellschaft (PEG), the guidelines from the British Society for Antimicrobial Chemotherapy, the VAP guideline of the Canadian Critical Care trials group, as well as the new German S3-guideline for HAP were examined.
Results
All guidelines are based on grading systems that assess the evidence underlying the recommendations. However, each guideline uses different grading systems. One common aspect of these guidelines is the risk assessment of the patients for decision making regarding IIAT. Most guidelines have different recommendations depending on the risk of the presence of multidrug resistant (MDR) bacteria. In guidelines using risk assessment, for low-risk patients (early onset, no MDR risk) aminopenicillins with beta-lactamase inhibitors (BLI), second or third generation cephalosporins, quinolones, or ertapenem are recommended. For patients with higher risk, imipenem, meropenem, fourth generation cephalosporins, ceftazidime or piperacillin/tazobactam are recommended. The PEG recommendations include a combination therapy in cases of very high risk (late onset, MDR risk, ICU, and organ failure) of either piperacillin/tazobactam, dori-, imi- or meropenem or cefepime or ceftazidime with ciprofloxacin, levofloxacin, fosfomycin or an aminoglycoside. For the treatment of HAP caused by methicillin-resistant Staphylococcus aureus (MRSA), either linezolid or vancomycin is recommended. With regard to the ZEPHyR-trial, linezolid has shown higher cure rates but, no difference in overall survival. Economic analyses show the relevance of guideline-adherent IIAT (GA-IIAT). Besides significantly better clinical outcomes, patients with GA-IIAT cause significantly lower costs (€28,033 versus (vs) €36,139) (P=0.006) and have a shorter length of stay in hospital (23.9 vs 28.3 days) (P=0.022).
Conclusion
We conclude that most current treatment guidelines take into account the individual patient risk and that the correct choice of IIAT affects clinical as well as economical outcomes.
Background: We undertook a systematic review and meta-analysis of randomized trials to explore the effectiveness of oral chlorhexidine on nosocomial pneumonia, causative bacteria, and mortality. Methods: PubMed, Embase, and the Cochrane Register of Controlled Trials were searched for randomized trials in critically ill patients receiving oral chlorhexidine. Odds ratios (OR) were pooled with the random effects model. Results: Twenty-two randomized trials including 4,277 patients were identified. Chlorhexidine significantly reduced the incidence of nosocomial pneumonia (OR 0.66; 95% confidence interval [CI] 0.51-0.85) and ventilator-associated pneumonia (OR 0.68, 95% CI 0.53-0.87). There was a significant reduction of nosocomial pneumonia due to both Gram-positive (OR 0.41; 95% CI 0.19- 0.85) and Gram-negative (OR 0.68; 95% CI 0.51-0.90) bacteria, but only pneumonia due to "normal" flora (OR 0.51; 95% CI 0.33-0.80). The subgroup analysis revealed a significant benefit of chlorhexidine on nosocomial pneumonia in surgical patients only (OR 0.52; 95% CI 0.33-0.82). Mortality was not affected. Conclusions: This review indicates that in critically ill, mainly surgical, patients, oral chlorhexidine reduces nosocomial pneumonia, ventilator-associated pneumonia, nosocomial pneumonia due to Gram-positive and Gram-negative bacteria, and due to "normal" flora, without affecting mortality. Further studies should explore the efficacy of oral chlorhexidine in non-surgical critically ill population.
Nosocomial pneumonia is common in critically ill patients and is associated with high mortality rates. The development of pneumonia in the intensive care unit (ICU) has been associated with bacterial colonisation within the oral cavity and translocation into the respiratory tract. Over recent years, several strategies have been employed and recommended for preventing ventilator associated pneumonia in the ICU. Chlorhexidine, a topical antiseptic, is a promising agent in preventing nosocomial pneumonia because of its wide antimicrobial spectrum of activity, ease of administration, minimal concerns of contributing to bacterial resistance and relatively benign side effect profile. To evaluate the safety and efficacy of chlorhexidine in preventing nosocomial pneumonia in critically ill patients, we conducted a literature search by using PubMed, EMBASE, CINAHL, Web of Science, and MEDLINE databases; Google Scholar, and the Cochrane Central Register of Controlled Trials (1966– February 2013) for relevant studies. Overall, seven clinical trials were identified. These studies showed mixed results and the majority failed to demonstrate a significant reduction in the incidence of nosocomial pneumonia with the use of chlorhexidine. However, the cardiothoracic surgery ICU patient population may benefit from its use. Further studies are warranted to clearly define the role of chlorhexidine in preventing nosocomial pneumonia.
Oral decontamination is proposed to be an effective prevention of ventilator-associated pneumonia (VAP).
The objective of this paper was to evaluate the effectiveness of oral decontamination in adult patients undergoing ventilation for more than 48h.
We included all randomized controlled trials that used oral topical decontamination in adult patients from any population requiring mechanical ventilation for more than 48h, versus placebo, normal saline, or standard oral care.
Sixteen trials involving 2399 participants were included. Meta-analysis showed that oral topical antiseptics significantly reduced the incidence of VAP [risk ratio (RR): 0.66; 95% confidence interval (CI): 0.49-0.88]. There was a significant reduction of VAP in studies which investigated decontamination with antibiotic agents other than iseganan (RR: 0.27; 95% CI: 0.18-0.42). Neither antiseptics nor antibiotics affected all-cause mortality, duration of ventilation, or duration of intensive care unit (ICU) stay.
Oral decontamination reduced the incidence of VAP in adults undergoing ventilation, but did not affect all-cause mortality, duration of ventilation, or duration of ICU stay in ventilated patients. Further evidence from higher quality trials is necessary.
Systematic reviews and meta-analyses are essential to summarise evidence relating to efficacy and safety of healthcare interventions accurately and reliably. The clarity and transparency of these reports, however, are not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.
Since the development of the QUOROM (quality of reporting of meta-analysis) statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realising these issues, an international group that included experienced authors and methodologists developed PRISMA (preferred reporting items for systematic reviews and meta-analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.
The PRISMA statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this explanation and elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA statement, this document, and the associated website (www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
This report updates, expands, and replaces the previously published CDC "Guideline for Prevention of Nosocomial Pneumonia". The new guidelines are designed to reduce the incidence of pneumonia and other severe, acute lower respiratory tract infections in acute-care hospitals and in other health-care settings (e.g., ambulatory and long-term care institutions) and other facilities where health care is provided. Among the changes in the recommendations to prevent bacterial pneumonia, especially ventilator-associated pneumonia, are the preferential use of oro-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; no recommendations were made about the use of sucralfate, histamine-2 receptor antagonists, or antacids for stress-bleeding prophylaxis. For prevention of health-care--associated Legionnaires disease, the changes include maintaining potable hot water at temperatures not suitable for amplification of Legionella spp., considering routine culturing of water samples from the potable water system of a facility's organ-transplant unit when it is done as part of the facility's comprehensive program to prevent and control health-care--associated Legionnaires disease, and initiating an investigation for the source of Legionella spp. when one definite or one possible case of laboratory-confirmed health-care--associated Legionnaires disease is identified in an inpatient hemopoietic stem-cell transplant (HSCT) recipient or in two or more HSCT recipients who had visited an outpatient HSCT unit during all or part of the 2-10 day period before illness onset. In the section on aspergillosis, the revised recommendations include the use of a room with high-efficiency particulate air filters rather than laminar airflow as the protective environment for allogeneic HSCT recipients and the use of high-efficiency respiratory-protection devices (e.g., N95 respirators) by severely immunocompromised patients when they leave their rooms when dust-generating activities are ongoing in the facility. In the respiratory syncytial virus (RSV) section, the new recommendation is to determine, on a case-by-case basis, whether to administer monoclonal antibody (palivizumab) to certain infants and children aged <24 months who were born prematurely and are at high risk for RSV infection. In the section on influenza, the new recommendations include the addition of oseltamivir (to amantadine and rimantadine) for prophylaxis of all patients without influenza illness and oseltamivir and zanamivir (to amantadine and rimantadine) as treatment for patients who are acutely ill with influenza in a unit where an influenza outbreak is recognized. In addition to the revised recommendations, the guideline contains new sections on pertussis and lower respiratory tract infections caused by adenovirus and human parainfluenza viruses and refers readers to the source of updated information about prevention and control of severe acute respiratory syndrome.
Nosocomial pneumonia is a significant cause of in-hospital morbidity and mortality. Oral care interventions have great potential to reduce the occurrence of nosocomial pneumonia. Studies using topical antiseptic agents yielded mixed results. We hypothesized that the use of chlorhexidine for oral decontamination would reduce the incidence of nosocomial pneumonia in patients requiring mechanical ventilation.
This study is a meta-analysis of randomized controlled trials assessing the effect of chlorhexidine on the incidence of nosocomial pneumonia. Data sources were Medline, EMBASE, Cochrane library, citation review of relevant primary and review articles, and contact with expert informants. Out of 1,251 articles screened, 4 randomized, controlled trials were identified that included a total of 1,202 patients. Descriptive and outcome data were extracted by two reviewers independently. Main outcome measures were the incidence of nosocomial pneumonia, and mortality. A random effects model was used.
The incidence of nosocomial pneumonia in the control group was 7% (41 out of 615) compared to 4% (24 out of 587) in the treatment group. Gram-negative bacteria accounted for 78% of the total isolates, with Pseudomonas aeruginosa being the most frequently isolated pathogen irrespective of the intervention provided. Duration of mechanical ventilation and intensive care unit length of stay were comparable between the two groups. Overall, the use of oral decontamination with chlorhexidine did not affect the incidence of nosocomial pneumonia (odds ratio of 0.42; 95% confidence interval 0.16-1.06) or the mortality rate (odds ratio 0.77, 95% confidence interval 0.28-2.11).
The use of oral decontamination with chlorhexidine did not result in significant reduction in the incidence of nosocomial pneumonia in patients who received mechanical ventilation, nor altered the mortality rate. The lack of benefit may reflect the few studies conducted in this area. Future trials should focus on a combination strategy of mechanical and pharmacological interventions.
Our objective was to develop an instrument to assess the methodological quality of systematic reviews, building upon previous tools, empirical evidence and expert consensus.
A 37-item assessment tool was formed by combining 1) the enhanced Overview Quality Assessment Questionnaire (OQAQ), 2) a checklist created by Sacks, and 3) three additional items recently judged to be of methodological importance. This tool was applied to 99 paper-based and 52 electronic systematic reviews. Exploratory factor analysis was used to identify underlying components. The results were considered by methodological experts using a nominal group technique aimed at item reduction and design of an assessment tool with face and content validity.
The factor analysis identified 11 components. From each component, one item was selected by the nominal group. The resulting instrument was judged to have face and content validity.
A measurement tool for the 'assessment of multiple systematic reviews' (AMSTAR) was developed. The tool consists of 11 items and has good face and content validity for measuring the methodological quality of systematic reviews. Additional studies are needed with a focus on the reproducibility and construct validity of AMSTAR, before strong recommendations can be made on its use.
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.
Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide Summary points Failure to consider the quality of evidence can lead to misguided recommendations; hormone replacement therapy for post-menopausal women provides an instructive example High quality evidence that an intervention’s desirable effects are clearly greater than its undesirable effects, or are clearly not, warrants a strong recommendationUncertainty about the trade-offs (because of low quality evidence or because the desirable and undesirable effects are closely balanced) warrants a weak recommendationGuidelines should inform clinicians what the quality of the underlying evidence is and whether recommendations are strong or weakThe Grading of Recommendations Assessment, Development and Evaluation (GRADE ) approach provides a system for rating quality of evidence and strength of recommendations that is explicit, comprehensive, transparent, and pragmatic and is increasingly being adopted by organisations worldwideGuideline developers around the world are inconsistent in how they rate quality of evidence and grade strength of recommendations. As a result, guideline users face challenges in understanding the messages that grading systems try to communicate. Since 2006 the BMJ has requested in its “Instructions to Authors” on bmj.com that authors should preferably use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for grading evidence when submitting a clinical guidelines article. What was behind this decision?In this first in a series of five articles we will explain why many organisations use formal systems to grade evidence and recommendations and why this is important for clinicians; we will focus on the GRADE approach to recommendations. In the next two articles we will examine how the GRADE system categorises quality of evidence and strength of recommendations. The final two articles will …
Study objective
The purpose of this study was to test the effectiveness of oropharyngeal decontamination on nosocomial infections in a comparatively homogeneous population of patients undergoing heart surgery.
Design
This was a prospective, randomized, double-blind, placebo-controlled clinical trial. Experimental and control groups were selected for similar infection risk parameters.
Setting
Cardiovascular ICU of a tertiary care hospital.
Patients
Three hundred fifty-three consecutive patients undergoing coronary artery bypass grafting, valve, or other open heart surgical procedures were randomized to an experimental (n=173) or control (n=180) group. Heart and lung transplantations were excluded.
Interventions
The experimental drug chosen was 0.12% chlorhexidine gluconate (CHX) oral rinse.
Measurements and results
The overall nosocomial infection rate was decreased in the CHX-treated patients by 65% (24/180 vs 8/173; p<0.01). We also noted a 69% reduction in the incidence of total respiratory tract infections in the CHX-treated group (17/180 vs 5/173; p<0.05). Gram-negative organisms were involved in significantly less (p<0.05) of the nosocomial infections and total respiratory tract infections by 59% and 67%, respectively. No change in bacterial antibiotic resistance patterns in either group was observed. The use of nonprophylactic IV antibiotics was lowered by 43% (42/180 vs 23/173; p<0.05). A reduction in mortality in the CHX-treated group was also noted (1.16% vs 5.56%).
Conclusions
Inexpensive and easily applied oropharyngeal decontamination with CHX oral rinse reduces the total nosocomial respiratory infection rate and the use of nonprophylactic systemic antibiotics in patients undergoing heart surgery. This results in significant cost savings for those patients who avoid additional antibiotic treatment.
Background and Purpose: Ventilator-associated pneumonia (VAP) is an important nosocomial infection worldwide, which leads to increased length of hospital stay, healthcare costs and mortality. Evidence on oral decontamination with antiseptic in reducing VAP is limited. Hence, a meta-analysis was performed to determine the effect of chlorhexidine oral decontamination in the reduction of VAP in mechanically ventilated patients Methods: An extensive literaturereview was conducted using the following databases: CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, EMBASE, CENTRAL, and the Google search engine. Retrieved articles were selected based on the methodological quality, inclusion criteria and analysed to find the pooled effect size. Results: The nine trials included in this meta-analysis revealed a significant reduction in the incidence of VAP among patients who received prophylactic oral decontamination with Chlorhexidine. However no significant effect was found in reducing overall mortality rate among the mechanically ventilated patients. Conclusion: The safety profile regarding the possible selection and induction of antibiotic resistance and presumed cost benefits of Chlorhexidine make it a highly attractive intervention for the prevention of VAP. This meta-analysis indicated that chlorhexidine can serve as a cost-effective and safe antiseptic in preventing VAP in mechanically ventilated patients.
Importance
Regular oral care with chlorhexidine gluconate is standard of care for patients receiving mechanical ventilation in most hospitals. This policy is predicated on meta-analyses suggesting decreased risk of ventilator-associated pneumonia, but these meta-analyses may be misleading because of lack of distinction between cardiac surgery and non–cardiac surgery studies, conflation of open-label vs double-blind investigations, and insufficient emphasis on patient-centered outcomes such as duration of mechanical ventilation, length of stay, and mortality.Objective
To evaluate the impact of routine oral care with chlorhexidine on patient-centered outcomes in patients receiving mechanical ventilation.Data Sources
PubMed, Embase, CINAHL, and Web of Science from inception until July 2013 without limits on date or language.Study Selection
Randomized clinical trials comparing chlorhexidine vs placebo in adults receiving mechanical ventilation. Of 171 unique citations, 16 studies including 3630 patients met inclusion criteria.Data Extraction and Synthesis
Eligible trials were independently identified, evaluated for risk of bias, and extracted by 2 investigators. Differences were resolved by consensus. We stratified studies into cardiac surgery vs non–cardiac surgery and open-label vs double-blind investigations. Eligible studies were pooled using random-effects meta-analysis.Main Outcomes and Measures
Ventilator-associated pneumonia, mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay, antibiotic prescribing.Results
There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine (relative risk [RR], 0.56 [95% CI, 0.41-0.77]) but no significant difference in ventilator-associated pneumonia risk in double-blind studies of non–cardiac surgery patients (RR, 0.88 [95% CI, 0.66-1.16]). There was no significant mortality difference between chlorhexidine and placebo in cardiac surgery studies (RR, 0.88 [95% CI, 0.25-2.14]) and nonsignificantly increased mortality in non–cardiac surgery studies (RR, 1.13 [95% CI, 0.99-1.29]). There were no significant differences in mean duration of mechanical ventilation or intensive care length of stay. Data on hospital length of stay and antibiotic prescribing were limited.Conclusions and Relevance
Routine oral care with chlorhexidine prevents nosocomial pneumonia in cardiac surgery patients but may not decrease ventilator-associated pneumonia risk in non–cardiac surgery patients. Chlorhexidine use does not affect patient-centered outcomes in either population. Policies encouraging routine oral care with chlorhexidine for non–cardiac surgery patients merit reevaluation.
As part of the ventilator care bundle, the Department of Health (DH) in the U.K. recommends the use of chlorhexidine (CHX) for oral care to prevent the occurrence of ventilator-associated pneumonia (VAP) in all mechanically ventilated patients. Due to the heterogenous nature of this population, however, it is important to consider whether such recommendations are also relevant to specific critical care patient population groups. This article reviews the available scientific evidence on the use of CHX in the prevention of VAP, with a focus on critically ill mechanically ventilated patients who have liver dysfunction. Findings will be discussed with reference to the wider research literature in order to make recommendations for future practice.
Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in persons who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions may reduce the risk of VAP in these patients.
To assess the effects of OHC on the incidence of VAP in critically ill patients receiving mechanical ventilation in intensive care units (ICUs) in hospitals.
We searched the Cochrane Oral Health Group's Trials Register (to 14 January 2013), CENTRAL (The Cochrane Library 2012, Issue 12), MEDLINE (OVID) (1946 to 14 January 2013), EMBASE (OVID) (1980 to 14 January 2013), LILACS (BIREME) (1982 to 14 January 2013), CINAHL (EBSCO) (1980 to 14 January 2013), Chinese Biomedical Literature Database (1978 to 14 January 2013), China National Knowledge Infrastructure (1994 to 14 January 2013), Wan Fang Database (January 1984 to 14 January 2013), OpenGrey and ClinicalTrials.gov (to 14 January 2013). There were no restrictions regarding language or date of publication.
We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation.
Two review authors independently assessed all search results, extracted data and undertook risk of bias. We contacted study authors for additional information. Trials with similar interventions and outcomes were pooled reporting odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes using random-effects models unless there were fewer than four studies.
Thirty-five RCTs (5374 participants) were included. Five trials (14%) were assessed at low risk of bias, 17 studies (49%) were at high risk of bias, and 13 studies (37%) were assessed at unclear risk of bias in at least one domain. There were four main comparisons: chlorhexidine (CHX mouthrinse or gel) versus placebo/usual care, toothbrushing versus no toothbrushing, powered versus manual toothbrushing and comparisons of oral care solutions.There is moderate quality evidence from 17 RCTs (2402 participants, two at high, 11 at unclear and four at low risk of bias) that CHX mouthrinse or gel, as part of OHC, compared to placebo or usual care is associated with a reduction in VAP (OR 0.60, 95% confidence intervals (CI) 0.47 to 0.77, P < 0.001, I(2) = 21%). This is equivalent to a number needed to treat (NNT) of 15 (95% CI 10 to 34) indicating that for every 15 ventilated patients in intensive care receiving OHC including chlorhexidine, one outcome of VAP will be prevented. There is no evidence of a difference between CHX and placebo/usual care in the outcomes of mortality (OR 1.10, 95% CI 0.87 to 1.38, P = 0.44, I(2) = 2%, 15 RCTs, moderate quality evidence), duration of mechanical ventilation (MD 0.09, 95% CI -0.84 to 1.01 days, P = 0.85, I(2) = 24%, six RCTs, moderate quality evidence), or duration of ICU stay (MD -0.21, 95% CI -1.48 to 1.89 days, P = 0.81, I(2) = 9%, six RCTs, moderate quality evidence). There was insufficient evidence to determine whether there is a difference between CHX and placebo/usual care in the outcomes of duration of use of systemic antibiotics, oral health indices, microbiological cultures, caregivers preferences or cost. Only three studies reported any adverse effects, and these were mild with similar frequency in CHX and control groups.From three trials of children aged from 0 to 15 years (342 participants, moderate quality evidence) there is no evidence of a difference between OHC with CHX and placebo for the outcomes of VAP (OR 1.07, 95% CI 0.65 to 1.77, P = 0.79, I(2) = 0%), or mortality (OR 0.73, 95% CI 0.41 to 1.30, P = 0.28, I(2) = 0%), and insufficient evidence to determine the effect on the outcomes of duration of ventilation, duration of ICU stay, use of systemic antibiotics, plaque index, microbiological cultures or adverse effects, in children.Based on four RCTs (828 participants, low quality evidence) there is no evidence of a difference between OHC including toothbrushing (± CHX) compared to OHC without toothbrushing (± CHX) for the outcome of VAP (OR 0.69, 95% CI 0.36 to 1.29, P = 0.24 , I(2) = 64%) and no evidence of a difference for mortality (OR 0.85, 95% CI 0.62 to 1.16, P = 0.31, I(2) = 0%, four RCTs, moderate quality evidence). There is insufficient evidence to determine whether there is a difference due to toothbrushing for the outcomes of duration of mechanical ventilation, duration of ICU stay, use of systemic antibiotics, oral health indices, microbiological cultures, adverse effects, caregivers preferences or cost.Only one trial compared use of a powered toothbrush with a manual toothbrush providing insufficient evidence to determine the effect on any of the outcomes of this review.A range of other oral care solutions were compared. There is some weak evidence that povidone iodine mouthrinse is more effective than saline in reducing VAP (OR 0.35, 95% CI 0.19 to 0.65, P = 0.0009, I(2) = 53%) (two studies, 206 participants, high risk of bias). Due to the variation in comparisons and outcomes among the trials in this group there is insufficient evidence concerning the effects of other oral care solutions on the outcomes of this review.
Effective OHC is important for ventilated patients in intensive care. OHC that includes either chlorhexidine mouthwash or gel is associated with a 40% reduction in the odds of developing ventilator-associated pneumonia in critically ill adults. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There is no evidence that OHC including both CHX and toothbrushing is different from OHC with CHX alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP.
Objective
To determine the effectiveness of oral care in preventing pneumonia associated with mechanical ventilation (VAP).
Background and objectiveMechanical ventilation is used in about one third of patients in intensive cares units (ICU). Ventilator Associated-Pneumonia (VAP) is a frequent infectious complication, affecting approximately 8 to 28% patients. Strategies to prevent the development of VAP are key factors in the management of ICU patients. There have been proposed several strategies to prevent VAP. One of these is oral hygiene with clorhexidine. We evaluated the effect of chlorhexidine on the prevention of VAP.
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.
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.
STUDY OFJECTIVE: The purpose of this study was to test the effectiveness of oropharyngeal decontamination on nosocomial infections in a comparatively homogeneous population of patients undergoing heart surgery.
This was a prospective, randomized, double-blind, placebo-controlled clinical trial. Experimental and control groups were selected for similar infection risk parameters. SEETTING: Cardiovascular ICU of a tertiary care hospital.
Three hundred fifty-three consecutive patients undergoing coronary artery bypass grafting, valve, or other open heart surgical procedures were randomized to an experimental (n=173) or control (n=180) group. Heart and lung transplantations were excluded.
The experimental drug chosen was 0.12% chlorhexidine gluconate (CHX) oral rinse.
The overall nosocomial infection rate was decreased in the CHX-treated patients by 65% (24/180 vs 8/173; p<0.01). We also noted a 69% reduction in the incidence of total respiratory tract infections in the CHX-treated group (17/180 vs 5/173; p<0.05). Gram-negative organisms were involved in significantly less (p<0.05) of the nosocomial infections and total respiratory tract infections by 59% and 67%, respectively. No change in bacterial antibiotic resistance patterns in either group was observed. The use of nonprophylactic IV antibiotics was lowered by 43% (42/180 vs 23/173; p<0.05). A reduction in mortality in the CHX-treated group was also noted (1.16% vs 5.56%).
Inexpensive and easily applied oropharyngeal decontamination with CHX oral rinse reduces the total nosocomial respiratory infection rate and the use of nonprophylactic systemic antibiotics in patients undergoing heart surgery. This results in significant cost savings for those patients who avoid additional antibiotic treatment.
Decreasing the levels of bacteria in the oropharynx should reduce the prevalence of nosocomial pneumonia.
To test the effectiveness of 0.12% chlorhexidine gluconate oral rinse in decreasing microbial colonization of the respiratory tract and nosocomial pneumonia in patients undergoing open heart surgery.
A prospective, randomized, case-controlled clinical trial design was used. Peridex (0.12% chlorhexidine gluconate) was the experimental drug, and Listerine (phenolic mixture) was the control drug. A total of 561 patients undergoing aortocoronary bypass or valve surgery requiring cardiopulmonary bypass were randomized to an experimental (n = 270) or a control (n = 291) group. Nosocomial pneumonia was diagnosed by using the criteria established by the Centers for Disease Control and Prevention.
The overall rate of nosocomial pneumonia was reduced by 52% (4/270 vs 9/291; P = .21) in the Peridex-treated patients. Among patients intubated for more than 24 hours who had cultures that showed microbial growth (all pneumonias occurred in this group), the pneumonia rate was reduced by 58% (4/19 vs 9/18; P = .06) in patients treated with Peridex. In patients at highest risk for pneumonia (intubated > 24 hours, with cultures showing the most growth), the rate was 71% lower in the Peridex group than in the Listerine group (2/10 vs 7/10; P = .02).
Although rates of nosocomial pneumonia were lower in patients treated with Peridex than in patients treated with Listerine, the difference was significant only in those patients intubated more than 24 hours who had the highest degree of bacterial colonization.
Nosocomial infections are an important cause of morbidity and mortality after cardiac surgery. Decolonization of endogenous potential pathogenic microorganisms is important in the prevention of nosocomial infections.
To determine the efficacy of perioperative decontamination of the nasopharynx and oropharynx with 0.12% chlorhexidine gluconate for reduction of nosocomial infection after cardiac surgery.
A prospective, randomized, double-blind, placebo-controlled clinical trial conducted at the Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands, between August 1, 2003, and September 1, 2005. Of 991 patients older than 18 years undergoing elective cardiothoracic surgery during the study interval, 954 were eligible for analysis.
Oropharyngeal rinse and nasal ointment containing either chlorhexidine gluconate or placebo.
Incidence of nosocomial infection, in addition to the rate of Staphylococcus aureus nasal carriage and duration of hospital stay.
The incidence of nosocomial infection in the chlorhexidine gluconate group and placebo group was 19.8% and 26.2%, respectively (absolute risk reduction [ARR], 6.4%; 95% confidence interval [CI], 1.1%-11.7%; P = .002). In particular, lower respiratory tract infections and deep surgical site infections were less common in the chlorhexidine gluconate group than in the placebo group (ARR, 6.5%; 95% CI, 2.3%-10.7%; P = .002; and 3.2%; 95% CI, 0.9%-5.5%; P = .002, respectively). For the prevention of 1 nosocomial infection, 16 patients needed to be treated with chlorhexidine gluconate. A significant reduction of 57.5% in S aureus nasal carriage was found in the chlorhexidine gluconate group compared with a reduction of 18.1% in the placebo group (P<.001). Total hospital stay for patients treated with chlorhexidine gluconate was 9.5 days compared with 10.3 days in the placebo group (ARR, 0.8 days; 95% CI, 0.24-1.88; P = .04).
Decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate appears to be an effective method to reduce nosocomial infection after cardiac surgery.
clinicaltrials.gov Identifier: NCT00272675.
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.
Several randomized controlled trials (RCTs) have examined the influence of oral chlorhexidine (CHX) in preventing nosocomial lower respiratory tract infection (LRTI). Most have failed to demonstrate a reduction in the incidence of LRTI. The present meta-analysis summarizes the effect of oral CHX on the development of LRTI. RCTs were identified through searching PubMed, MEDLINE and the Cochrane Central Register of Controlled Trials databases. Those describing the use of chlorhexidine for oral decontamination and reporting the incidence of LRTI as a study outcome were included in the meta-analysis. Seven RCTs met the inclusion criteria; pooling the results from these reveals a reduction in the relative risk (RR) of LRTI in the CHX group [RR(random): 0.58, 95% confidence interval (CI): 0.45-0.74; and RR(fixed): 0.56, CI95: 0.44-0.72, respectively]. Further analyses showed that this result applied only to patients ventilated for up to 48h (RR(random): 0.58, CI95: 0.45-0.74; and RR(fixed): 0.56, 95% CI: 0.44-0.72). Oral CHX should be included among preventive measures performed to reduce nosocomial LRTI. Whether it has an impact on the development of LRTI in patients requiring mechanical ventilation for a longer period of time remains unresolved.
To determine the efficacy ofperioperative decontamination of the nasopharynx and oropharynx in reducing nosocomial infection after cardiac surgery with the use of 0.12% chlorhexidine.
Randomized, double-blind, placebo-controlled clinical trial (www.clinicaltrials.gov; identifier NCT00272675).
The trial was conducted at the Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands, from 1 August 2003-31 August 2005. Of 991 patients older than 18 years who underwent elective cardiothoracic surgery during the study interval, 954 were eligible for the study. They were given an oropharyngeal rinse and nasal ointment was applied which contained either chlorhexidine or placebo. Clinical outcomes were incidence of nosocomial infection, rate of Staphylococcus aureus nasal carriage and duration of hospital stay.
The incidence ofnosocomial infection in the chlorhexidine and placebo groups was 19.8% and 26.2% respectively (absolute risk reduction (ARR): 6.4%; 95% CI: 1.1-11.7; p = 0.002). In particular, lower respiratory tract infections and deep surgical site infections were less common in the chlorhexidine group than in the placebo group (ARR: 6.5%; 95% CI: 2.3-10.7; p = 0.002 and 3.2%; 95% CI: 0.9-5.5; p = 0.002, respectively). For the prevention of one nosocomial infection, 16 patients needed to be treated with chlorhexidine. A significant reduction in S. aureus nasal carriage was found in the chlorhexidine group (57.5%) as compared with a reduction of 18.1% in the placebo group (p < 0.0001). Total hospital stay for patients treated with chlorhexidine was 9.5 days compared with 10.3 days in the placebo group (95% CI: 0.24-1.88; p = 0.04).
Decontamination of the nasopharynx and oropharynx with chlorhexidine appeared to be an effective method to reduce nosocomial infection after cardiac surgery.
Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia
American Thoracic Society, Infectious Diseases Society of America.
Guidelines for the management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated pneumonia. Am J
Respir Crit Care Med. 2005;171:388-416.