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

Preintubation application of oral chlorhexidine does not provide additional benefit in prevention of early-onset ventilator-associated pneumonia

BACKGROUND

Daily application of oral chlorhexidine gluconate (CHX) following intubation to reduce the risk of ventilator-associated pneumonia (VAP) is now the standard of care in many ICUs. This randomized clinical trial evaluated the benefit of adding a preintubation CHX dose to the known benefit of postintubation CHX to reduce the risk of early-onset VAP. A secondary aim was to test the effect of a preintubation oral application of CHX on early endotracheal tube (ETT) colonization.

METHODS

Subjects (N = 314) were recruited from two teaching hospitals and were randomly assigned to oral application of 5 mL CHX 0.12% solution before intubation (intervention group, n = 157), or to a control group (n = 157) who received no CHX before intubation. All subjects received CHX bid after intubation. Groups were compared using a repeated-measures model with Clinical Pulmonary Infection Score (CPIS) as the response variable. In a planned subset of subjects, ETTs were cultured at extubation.

RESULTS

Application of a preintubation dose of CHX did not provide benefit over the intervention period beyond that afforded by daily oral CHX following intubation. ETT colonization at extubation was < 20% in both groups (no statistically significant difference). Mean CPIS remained below 6 (VAP threshold score) in both groups.

CONCLUSIONS

Although it is feasible to deliver CHX prior to intubation (including emergent or urgent intubation), the results suggest that preintubation CHX may be inconsequential when the ventilator bundle, including daily oral CHX, is in place. During the preintubation period, providers should focus their attention on other critical activities.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00893763; URL: www.clinicaltrials.gov.

Myocardial injury after surgery is a risk factor for weaning failure from mechanical ventilation in critical patients undergoing major abdominal surgery

Background

Myocardial injury after noncardiac surgery (MINS) is a newly proposed concept that is common among adults undergoing noncardiac surgery and associated with substantial mortality. We analyzed whether MINS was a risk factor for weaning failure in critical patients who underwent major abdominal surgery.

Methods

This retrospective study was conducted in the Department of Critical Care Medicine of Peking University People's Hospital. The subjects were all critically ill patients who underwent major abdominal surgery between January 2011 and December 2013. Clinical and laboratory parameters during the perioperative period were investigated. Backward stepwise regression analysis was performed to evaluate MINS relative to the rate of weaning failure. Age, hypertension, chronic renal disease, left ventricular ejection fraction before surgery, Acute Physiologic and Chronic Health Evaluation II score, pleural effusion, pneumonia, acute kidney injury, duration of mechanical ventilation before weaning and the level of albumin after surgery were treated as independent variables.

Results

This study included 381 patients, of whom 274 were successfully weaned. MINS was observed in 42.0% of the patients. The MINS incidence was significantly higher in patients who failed to be weaned compared to patients who were successfully weaned (56.1% versus 36.5%; P<0.001). Independent predictive factors of weaning failure were MINS, age, lower left ventricular ejection fraction before surgery and lower serum albumin level after surgery. The MINS odds ratio was 4.098 (95% confidence interval, 1.07 to 15.6; P = 0.04). The patients who were successfully weaned had shorter hospital stay lengths and a higher survival rate than those who failed to be weaned.

Conclusion

MINS is a risk factor for weaning failure from mechanical ventilation in critical patients who have undergone major abdominal surgery, independent of age, lower left ventricular ejection fraction before surgery and lower serum albumin levels after surgery.

Hospital admissions for pneumonia more likely with concomitant dental infections

OBJECTIVE

The objective of this study is to determine if the presence of dental infection is associated with an increased likelihood of hospital admission following an emergency department (ED) visit among patients diagnosed with pneumonia. We hypothesized that the presence of a dental infection may worsen the clinical symptoms in ED patients diagnosed with pneumonia and are using hospital admission as a marker of worsening clinical severity.

MATERIALS AND METHODS

We analyzed the data from the 2008 Nationwide Emergency Department Sample and used Poisson regression with robust estimates of variance to obtain prevalence ratios (PRs) with the appropriate adjustments for complex survey sampling.

RESULTS

In the final multivariable model, there was a 19% increase in the likelihood of hospital admission following an ED visit among pneumonia patients diagnosed with dental infection compared to those without dental infection (PR = 1.19, 95% CI = 1.11-1.27). In an exploratory multivariable analysis, pneumonia patients diagnosed with dental caries had a 29% increase in the likelihood of admission compared to those not having dental caries (PR = 1.29, 95% CI = 1.23-1.34). These findings remained consistent in a subgroup analysis among patients with less clinically severe forms of pneumonia.

CONCLUSIONS

Dental infections may worsen the clinical symptoms in ED patients with pneumonia increasing their likelihood for hospital admission. Dental caries may be a marker for poor oral hygiene and increased dental plaque rather than serve directly as a source of respiratory pathogens.

CLINICAL RELEVANCE

The findings suggest that an increased focus on preventive oral health may reduce the need for admission following an ED visit for patients diagnosed with pneumonia.

Effectiveness of a dental care intervention in the prevention of lower respiratory tract nosocomial infections among intensive care patients: a randomized clinical trial

OBJECTIVE

To evaluate whether dental treatment may enhance oral antisepsis, thus preventing more effectively lower respiratory tract infections (LRTIs) among critically ill patients.

DESIGN

Observer-blind randomized clinical trial.

SETTING

General intensive care unit (ICU) for adult patients.

PATIENTS

We analyzed data from 254 adult patients who stayed for at least 48 hours in the ICU.

INTERVENTION

Patients were randomized by means of rolling dice. The experimental group (n = 127) had access to dental care provided by a dental surgeon, 4-5 times a week. Besides routine oral hygiene, care also included teeth brushing, tongue scraping, removal of calculus, atraumatic restorative treatment of caries, and tooth extraction. The control group (n = 127) had access to routine oral hygiene only, which included the use of chlorhexidine as a mouth rinse, which was performed by the ICU nurse staff.

RESULTS

The primary study outcome was the LRTI incidence, which was 8.7% in the experimental group and 18.1% in the control group (adjusted relative risk [RR], 0.44 [95% confidence interval (CI), 0.20-0.96]; P = .04). Ventilator-associated pneumonia rates per 1,000 ventilator-days were 16.5 (95% CI, 9.8-29.5) in the control group and 7.6 (95% CI, 3.3-15.0) in the experimental group (P < .05). Mortality rates were similar between both study groups: 31.5% in the control group versus 29.1% in the experimental group (adjusted RR, 0.93 [95% CI, 0.52-1.65]; P = .796). No severe adverse events related to oral care were observed during the study.

CONCLUSION

Dental treatment was safe and effective in the prevention of LRTI among critically ill patients who were expected to stay at least 48 hours in the ICU.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry, affiliated with the World Health Organization's International Clinical Trial Registry Platform: U1111-1152-2671.

Periodontal therapy for the management of cardiovascular disease in patients with chronic periodontitis

BACKGROUND

There is an association between chronic periodontitis and cardiovascular disease (CVD). However, it is not known whether periodontal therapy could prevent or manage CVD in patients with chronic periodontitis.

OBJECTIVES

The objective of this systematic review was to investigate the effects of periodontal therapy in preventing the occurrence of, and management or recurrence of, CVD in patients with chronic periodontitis.

SEARCH METHODS

The electronic databases that were searched were the Cochrane Oral Health Group's Trials Register (to 7 April 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 3), MEDLINE via OVID (1946 to 7 April 2014), EMBASE via OVID (1980 to 7 April 2014), CINAHL via EBSCO (1937 to 7 April 2014), OpenGrey (to 7 April 2014), the Chinese BioMedical Literature Database (1978 to April 2014), the China National Knowledge Infrastructure (1994 to April 2014) and the VIP database (1989 to April 2014). We searched the US National Institutes of Health Trials Register, the World Health Organization (WHO) Clinical Trials Registry Platform and Sciencepaper Online for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs were considered eligible. Studies were selected if they included patients with a diagnosis of chronic periodontitis and previous CVD (secondary prevention studies) or no CVD (primary prevention studies); patients in the intervention group received active periodontal therapy compared to maintenance therapy, no periodontal treatment or another kind of periodontal treatment in the control group.

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction and risk of bias assessment independently and in duplicate. Any discrepancies between the two authors were resolved by discussion or with a third review author. A formal pilot-tested data extraction form was adopted for the data extraction, and the Cochrane Collaboration's tool for risk of bias assessment was used for the critical appraisal of the literature.

MAIN RESULTS

No studies were identified that assessed primary prevention of CVD in people with periodontitis. One study involving 303 participants with ≥ 50% blockage of one coronary artery or a coronary event within three years, but not the three months prior, was included. The study was at high risk of bias due to deviation from the protocol treatment allocation and lack of follow-up data. The trial compared scaling and root planing (SRP) with community care for a follow-up period of six to 25 months. No data on deaths (all-cause or CVD-related) were reported. There was insufficient evidence to determine the effect of SRP and community care in reducing the risk of CVD recurrence in patients with chronic periodontitis (risk ratio (RR) 0.72; 95% confidence interval (CI) 0.23 to 2.22; very low quality evidence). The effects of SRP compared with community care on high-sensitivity C-reactive protein (hs-CRP) (mean difference (MD) 0.62; -1.45 to 2.69), the number of patients with high hs-CRP (RR 0.77; 95% CI 0.32 to 1.85) and adverse events (RR 9.06; 95% CI 0.49 to 166.82) were also not statistically significant. The study did not assess modifiable cardiovascular risk factors, other blood test results, heart function parameters or revascularisation procedures.

AUTHORS' CONCLUSIONS

We found very low quality evidence that was insufficient to support or refute whether periodontal therapy can prevent the recurrence of CVD in the long term in patients with chronic periodontitis. No evidence on primary prevention was found.

Oral health disparities in older adults: oral bacteria, inflammation, and aspiration pneumonia

Poor oral hygiene has been suggested to be a risk factor for aspiration pneumonia in the institutionalized and disabled elderly. Control of oral biofilm formation in these populations reduces the numbers of potential respiratory pathogens in the oral secretions, which in turn reduces the risk for pneumonia. Together with other preventive measures, improved oral hygiene helps to control lower respiratory infections in frail elderly hospital and nursing home patients.