Association between perioperative chlorhexidine oral care and postoperative pneumonia in non-cardiac surgical patients: A systematic review and meta-analysis

Perioperative Oral decontamination and ImmunoNuTrition (POINT) to prevent postoperative pulmonary complications in elderly patients scheduled for elective non-cardiac surgeries: protocol for a multicentre, randomised controlled trial

INTRODUCTION

Elderly patients are known to be vulnerable to postoperative pulmonary complications (PPCs), especially pneumonia. Apart from elder age, preoperative pulmonary diseases, anaemia, malnutrition, dysphagia and frailty may all be contributing factors to PPCs. Poor oral hygiene is a risk factor for PPC as well, as oropharyngeal microflora might be introduced to the lower respiratory tract following endotracheal intubation for general anaesthesia during surgery. Immune regulation, nutrition supplementation and improvement of oropharyngeal microflora might regulate immune and stress response and can be beneficial to elderly patients exposed to surgical stress. In this study, we will explore the effects of perioperative oral decontamination and immunonutrition supplementation on the incidence of postoperative pneumonia in high-risk elderly surgical patients.

METHODS AND ANALYSIS

This study is a multicentre, two-by-two factorial randomised controlled trial evaluating the efficacy of immunonutrition supplementation and oral chlorhexidine decontamination. A total of 592 patients aged 65 years and older who are scheduled for elective non-cardiac surgeries in seven tertiary hospitals in China will be recruited. Patients will be excluded if they have contraindications to the intervention. Patients will be randomised into four groups in a 1:1:1:1 ratio (oral decontamination vs routine oral care, immunonutrition supplementation vs routine nutrition advice). The primary outcome is the incidence of PPCs within 7 days after surgery. The secondary outcomes are the incidence of postoperative pneumonia, infectious complications, Comprehensive Complication Index, postoperative functional recovery, length of hospital stay and hospital expenses. Intention to treat principles will be applied to all outcomes. Descriptive analysis will be used to compare patients' baseline characteristics. Logistic regression will be used to compare the incidence of PPCs within 7 days after surgery between different groups.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Research Ethics Committee of Peking Union Medical College Hospital (I-23PJ953). All participants will provide written informed consent. Study results will be published in peer-reviewed journals and presented at academic conferences.

TRIAL REGISTRATION NUMBER

NCT05971810.

Risk factors of pneumonia after thoracic aortic surgery

OBJECTIVE

Pneumonia is a common complication and a significant cause of mortality following cardiovascular surgery. This study aimed to investigate the incidence and risk factors for pneumonia after thoracic aortic surgery.

METHODS

A retrospective review was conducted on the medical records of 380 patients who underwent thoracic aortic surgery between January 2016 and December 2019. Patients were classified into pneumonia and non-pneumonia groups based on postoperative outcomes. Pneumonia was further categorized as aspiration pneumonia, ventilation-associated pneumonia (VAP), or other types. Risk factors were identified through univariate and multivariate analyses.

RESULTS

Postoperative pneumonia during hospitalization occurred in 30 patients (7.9 %), including 18 cases of aspiration pneumonia (4.7 %) and 9 cases of VAP (2.4 %). Risk factors identified included hoarseness before surgery, aortic arch replacement, longer anesthesia time, longer intubation duration, necessity for tracheostomy, cerebrovascular disease after surgery, and postoperative recurrent laryngeal nerve paralysis. Multivariate analysis suggested that hoarseness before surgery and the necessity for tracheostomy were independent risk factors for pneumonia during hospitalization.

CONCLUSION

This study identified key risk factors for postoperative pneumonia after thoracic aortic surgery. These findings may aid in identifying high-risk patients and implementing preventive strategies to reduce postoperative pneumonia.

Predicting postoperative pulmonary infection in elderly patients undergoing major surgery: a study based on logistic regression and machine learning models

BACKGROUND

Postoperative pulmonary infection (POI) is strongly associated with a poor prognosis and has a high incidence in elderly patients undergoing major surgery. Machine learning (ML) algorithms are increasingly being used in medicine, but the predictive role of logistic regression (LR) and ML algorithms for POI in high-risk populations remains unclear.

METHODS

We conducted a retrospective cohort study of older adults undergoing major surgery over a period of six years. The included patients were randomly divided into training and validation sets at a ratio of 7:3. The features selected by the least absolute shrinkage and selection operator regression algorithm were used as the input variables of the ML and LR models. The random forest of multiple interpretable methods was used to interpret the ML models.

RESULTS

Of the 9481 older adults in our study, 951 developed POI. Among the different algorithms, LR performed the best with an AUC of 0.80, whereas the decision tree performed the worst with an AUC of 0.75. Furthermore, the LR model outperformed the other ML models in terms of accuracy (88.22%), specificity (90.29%), precision (44.42%), and F1 score (54.25%). Despite employing four interpretable methods for RF analysis, there existed a certain degree of inconsistency in the results. Finally, to facilitate clinical application, we established a web-friendly version of the nomogram based on the LR algorithm; In addition, patients were divided into three significantly distinct risk intervals in predicting POI.

CONCLUSIONS

Compared with popular ML algorithms, LR was more effective at predicting POI in older patients undergoing major surgery. The constructed nomogram could identify high-risk elderly patients and facilitate perioperative management planning.

TRIAL REGISTRATION

The study was retrospectively registered (NCT06491459).

The positive effects of preoperative chlorhexidine rinse to reduce postoperative pneumonia after kidney transplantation surgery

BACKGROUND

Postoperative pneumonia is one of the most observed hospital-acquired infections and increases the postoperative mortality rate. Further, it drives the healthcare systems under a severe financial burden. Preventing postoperative pneumonia is an incredibly challenging issue for clinicians. Since immunosuppression therapy, the patients who had kidney transplants are more vulnerable to postoperative infections. There is no data in the scientific literature focusing on the effects of preoperative oral care with chlorhexidine antiseptic solutions on postoperative pneumonia in kidney transplantation surgery cases. In the present research, we studied this topic.

METHODS

A prospective, randomized clinical trial was conducted at our institution between August 2020 and August 2022. Group A: Received 0.12 % chlorhexidine oral rinse preoperatively; Group B: Not received 0.12 % chlorhexidine oral rinse preoperatively. We analyzed the differences between the two trial groups using a chi-square or t-test. The Mann-Whitney U test was used for the categorical data.

RESULTS

Nine patients (17.6 %) were diagnosed with postoperative pneumonia in Group A and fourteen (25.9 %) in Group B (p < 0.05). Hospitalization time of Group B was prolonged (p < 0.05). In multivariate analysis, significant risk factors associated with postoperative pneumonia were advanced age, diabetes mellitus, smoking, delayed graft function and not gargling with 0.12 % chlorhexidine (p < 0.05).

CONCLUSIONS

To reduce postoperative pneumonia risk in patients undergoing kidney transplantation surgery, an oral health protocol including 0.12 % chlorhexidine mouth rinse seems beneficial.

Dental and oral management in the perioperative period of surgery: A scoping review

Dental and oral management (DOM) is a long-established treatment modality. This scoping review aimed to narratively review previous studies, examine the effects of perioperative DOM, and identify the available evidence. A literature search was conducted using the PubMed electronic database for studies published between January 1, 2000, and March 8, 2022. The search yielded 43 studies, most of which were published in the last 10 years. The results of this study confirmed that improved perioperative oral hygiene is effective in preventing postoperative pneumonia. Our results also suggested that preoperative DOM is effective in preventing postoperative surgical site infections. Perioperative DOM is effective in reducing the incidence of postoperative pneumonia, SSI, and postsurgical complications. Further studies are needed to elucidate the various mechanism of DOM and to examine efficient intervention methods and timing.

Effect of Different Concentrations of Chlorhexidine on Anti-Plaque in Oral Care Practice: A Systematic Review and Network Meta-Analysis

OBJECTIVES

The aim of this network meta-analysis was to compare the anti-plaque effects and adverse effects of different concentrations of chlorhexidine (CHX).

METHODS

PubMed, OVID Embase and the Cochrane Library were searched from inception to October 2023 for randomised controlled trials (RCTs) of different concentrations of CHX in healthy populations. Random-effects network meta-analyses were performed to summarise the evidence, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to rate the certainty of evidence. Cohen's d standardised mean differences were calculated as the measure of effect size.

RESULTS

Thirty-eight RCTs involving 2011 participants and six concentrations of CHX (0.2%, 0.12%, 0.1%, 0.3%, 1% and 0.06%) were included. The anti-plaque effects of CHX at all concentrations were compared with placebo. Moderate to very low certainty evidence established 0.2% CHX as the most effective on anti-plaque. 0.12% and 0.1% CHX also showed significant anti-plaque effects. However, the ranking probabilities showed that the adverse effects of 0.12% and 0.1% CHX were < 0.2% CHX.

CONCLUSIONS

Compared with placebo, 0.2%, 0.12% and 0.1% CHX had significant anti-plaque effects, with moderate to very low certainty evidence that 0.2% CHX was most effective on anti-plaque. However, 0.2% CHX had larger adverse effects than 0.12% and 0.1% CHX.

TRIAL REGISTRATION

PROSPERO: Number CRD: 42022327083.

Effect of perioperative oral care on postoperative infections in patients with cancer: A systematic review and meta-analysis

AIM

This systematic review aimed to assess the effect of non-pharmacologic perioperative oral hygiene care on reduced incidence of postoperative pneumonia (PP), surgical site infection (SSI), and the length of hospital stay in patients with cancer, and to describe the details of oral hygiene care.

METHODS

We searched seven databases. Eligibility criteria were based on perioperative oral hygiene care provided by healthcare professionals to patients aged ≥18 years who were surgically treated under general anesthesia and were evaluated for the incidence of PP and SSI. We reported risk ratios (RR) for dichotomous outcomes for PP and SSI using a fixed-effects model of meta-analysis.

RESULTS

The search resulted in 850 articles, among which two were randomized controlled trials (RCTs) and 21 were observational studies. Most studies indicated that dentists and medical care providers performed a combination of oral cleaning, and oral hygiene instructions. In RCTs, perioperative oral hygiene care significantly reduced the incidence of PP (RR, 0.86; p = .60), while in observational studies, perioperative oral hygiene care significantly reduced the incidence of PP (RR, 0.55; p < .001) and SSI (RR, 0.47; p < .001). The length of hospital stay was also significantly reduced (p < .05). However, the effectiveness of nursing intervention was not clear.

CONCLUSIONS

Perioperative oral hygiene care implemented by healthcare professionals prevented PP and SSI and reduced length of hospital stays for patients after cancer surgery. As daily perioperative oral hygiene care is performed by nurses, it is necessary to research the effects of oral hygiene by nurses in the future.

Oral hygiene prior to cardiac surgery to prevent infections: Randomized clinical trial

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, 1 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, 1 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.

CLINICAL TRIAL REGISTRATION

Site Ensaclinicos.gov.br number U1111-1214-2862.

DESCRIPTORS

Healthcare Associated Infections, Cardiovascular Diseases, Periodontal Diseases, Dental Biofilm, Cardiovascular Surgery.

Impact of oral/dental disease burden on postoperative infective complications: a prospective cohort study

OBJECTIVES

This prospective cohort study aimed to assess the association between dental disease burden and postoperative infective complications (POICs) in patients undergoing major surgical procedures under general anaesthesia.

METHODS

Pre-surgical dental assessment was undertaken on patients planned for major surgery. Demographic and surgical variables including putative risk factors for POICs and POIC status were documented. The univariable association between POIC status and each factor was examined. Those variables associated at P value ≤ 0.2 were candidates for inclusion in multiple logistic regression models. Backward stepwise variable selection was used to identify the independent predictors for POIC in the best fitting logistic regression model. The area under the receiver operating curve (AUC) was used to quantify the model's global classification performance.

RESULTS

Among the 285 patients, 49 patients (17.2%) had POICs. The independent predictors for POIC were expected length of hospital stay (4-6 days; odds ratio [OR] = 4.80, 95% confidence internal [CI]: 1.30-17.70, P = 0.018, 7-9 days; OR = 5.42, 95% CI: 1.51-19.41, P = 0.009, ≥ 10 days; OR = 28.80, 95% CI: 4.12-201.18, P < 0.001), four or more decayed teeth (OR = 6.03, 95% CI: 2.28-15.94, P < 0.001) and visible tongue plaque (OR = 3.21, 95% CI: 1.54-6.70, P = 0.002). The AUC was 0.78 (95% CI: 0.71-0.85) indicating good discrimination. A simple screening tool for POIC was developed.

CONCLUSIONS/CLINICAL RELEVANCE

In addition to systemic/surgical factors, this study identified clinically detected decayed teeth and visible tongue plaque as independent predictors for POICs. Preoperative dental assessment/care might be beneficial to assess risk for POICs and improve postoperative outcomes.

Poor Oral Health in Trauma Intensive Care Unit Patients: Application of a Novel Oral Health Score

Background: Although oral hygiene in patients in the intensive care unit (ICU) has been shown to reduce hospital-associated infections, baseline and progressive oral health are often not reported because of lack of a standardized tool. The Oral Health Risk Assessment Value Index (OHRAVI) is a comprehensive oral assessment validated by dental providers. This study hypothesizes that non-dental providers can use OHRAVI in trauma ICU patients with minimal training and acceptable inter-rater reliability (IRR). Patients and Methods: Dentulous adult patients in the ICU at a level 1 trauma center were scored, excluding those with severe orofacial trauma. The eight categories of the OHRAVI were scored 0 to 3 (best to worst) with summed total and index (average) score. Index scores 1 or less need routine oral care; greater than 1-2 require moderate care; and greater than 2-3 require extensive oromaxillofacial care. Inter-rater reliability was assessed by two to three raters with Krippendorff's α (≥0.80 for good and ≥0.667 for acceptable). Results: Eighty-four ratings were completed across 34 patients, with 16 patients (47%) scored by all three raters. Ten patients (29%) had an index score <1. The average index score for patients was 1.28 (median, 1.34; range, 0.63-2). Krippendorff's α for index score was 0.86. For individual categories, α ranged from 0.44 to 1, with six of the eight categories achieving an α ≥ 0.667. Conclusions: With minimal training, non-dental providers were able to use OHRAVI with a good IRR for index score and an acceptable/good IRR for most individual categories. This novel, simple, comprehensive oral health score could help standardize oral assessment and facilitate future studies of peri-operative oral hygiene interventions.

General Factors and Dental-Related Risk Factors for Postoperative Pneumonia or Infectious Complications: A Retrospective Study

Numerous studies report that perioperative oral care decreases the frequency of postoperative pneumonia or infection. However, no studies have analyzed the specific impact of oral infection sources on the postoperative course, and the criteria for preoperative dental care differ among institutions. This study aimed to analyze the factors and dental conditions present in patients with postoperative pneumonia and infection. Our results suggest that general factors related to postoperative pneumonia, including thoracic surgery, sex (male > female), the presence or absence of perioperative oral management, smoking history, and operation time, were identified, but there were no dental-related risk factors associated with it. However, the only general factor related to postoperative infectious complications was operation time, and the only dental-related risk factor was periodontal pocket (4 mm or higher). These results suggest that oral management immediately before surgery is sufficient to prevent postoperative pneumonia, but that moderate periodontal disease must be eliminated to prevent postoperative infectious complication, which requires periodontal treatment not only immediately before surgery, but also on a daily basis.

Frailty is associated with an increased risk of postoperative pneumonia in elderly patients following surgical treatment for lower-extremity fractures: A cross-sectional study

Elderly patients with lower-extremity fractures are at high risk of postoperative pneumonia (POP) after surgery due to longtime bed rest. This study aimed to explore whether preoperative frailty is an independent risk factor for POP in elderly patients undergoing surgical treatment for lower-extremity fractures. The study adopted a cross sectional design with 568 patients (≥60 years) admitted to a tertiary hospital in China from January 1, 2021 to June 30, 2022, for surgical intervention of a significant lower-extremity fracture. Preoperative frailty was assessed using the CFS (Clinical Frailty Scale). POP was assessed based on the classic diagnostic criteria reported in previous studies. Univariate and multiple logistic regression analyses were conducted to determine the impacts of preoperative frailty on POP. Of the 568 elderly patients, 65 (11.4%) developed pneumonia during postoperative hospitalization. There were significant differences among gender, hypoproteinemia, type of anesthesia, history of chronic obstructive pulmonary disease (COPD), and CFS scores. Multiple regression analysis revealed that the risk of POP in vulnerable, mildly frail, and severely frail patients increased by 2.38 times (P = .01, 95% CI [1.22-1.91]), 3.32 (P = .00, 95% CI [2.39-5.61]), and 5.36 (P = .00, 95% CI [3.95-6.52]), significantly. 12.8% of patients with hip fractures and 8.9% of patients with other main types of lower-extremity fractures developed POP. However, the difference between hip and non-hip fractures was not statistically significant (P > .05). Preoperative frailty increases the risk of POP in elderly patients after surgical treatment of main lower-extremity fractures. The severer the preoperative frailty is, the higher the risk of preoperative pneumonia is in elderly patients with lower-extremity fractures. CFS is simple and feasible for the assessment of frailty in elderly patients with lower-extremity fractures. Preoperative frailty assessment and appropriate management strategies should be considered in the perioperative management of elderly patients with lower-extremity fractures.

Identifying the role of preoperative oral/dental health care in post-esophagectomy pulmonary complications: a systematic review and meta-analysis

Esophageal surgery has traditionally been associated with high morbidity rates. Despite the recent advances in the field of minimally invasive surgery and the introduction of enhanced recovery after surgery (ERAS) protocols, post-esophagectomy morbidity, especially that attributed to the respiratory system, remains a concern. In that respect, preoperative intensification of oral care or introduction of structured oral/dental hygiene regimens may lead to tangible postoperative benefits associated with reduced morbidity (respiratory or otherwise) and length of hospital stay. A systematic literature search of the Medline, Embase, Web of Knowledge and clinicaltrials.gov databases was undertaken for studies reporting use of preoperative oral/dental hygiene improvement regimens in patients scheduled to undergo esophagectomy for esophageal cancer. Meta-analysis was performed using a random-effects model. After screening 796 unique studies, seven were deemed eligible for inclusion in the meta-analysis. Pooled results indicated equivalent postoperative pneumonia rates in the oral pretreatment group and control groups (8.7 vs. 8.5%, respectively); however, the odds for developing pneumonia were reduced by 50% in the pretreatment group (odds ratio 0.5, 95% C.I. 0.37 to 0.69, P < 0.001). No statistically significant difference was detected in the anastomotic leak (odds ratio 0.93, 95% C.I. 0.38 to 2.24, P = 0.87) and length of stay outcomes (mean difference 0.63, 95% C.I. -3.22 to 4.47, P = 0.75). Oral/dental pretreatment reduces the odds for developing post-esophagectomy pneumonia. This finding should be cautiously interpreted given the significant limitations inherent in this meta-analysis. Further investigation via well-designed clinical trials is thus warranted before implementation in routine practice can be recommended.

Pneumonia After Cardiovascular Surgery: Incidence, Risk Factors and Interventions

Postoperative pneumonia (POP) is prevalent in patients undergoing cardiovascular surgery, associated with poor clinical outcomes, prolonged hospital stay and increased medical costs. This article aims to clarify the incidence, risk factors, and interventions for POP after cardiovascular surgery. A comprehensive literature search was performed to identify previous reports involving POP after cardiovascular surgery. Current situation, predictors and preventive measures on the development of POP were collected and summarized. Many studies showed that POP was prevalent in various cardiovascular surgical types, and predictors varied in different studies, including advanced age, smoking, chronic lung disease, chronic kidney disease, cardiac surgery history, cardiac function, anemia, body mass index, diabetes mellitus, surgical types, cardiopulmonary bypass time, blood transfusion, duration of mechanical ventilation, repeated endotracheal intubation, and some other risk factors. At the same time, several targeted interventions have been widely reported to be effective to reduce the risk of POP and improve prognosis, including preoperative respiratory physiotherapy, oral care and subglottic secretion drainage. Through the review of the current status, risk factors and intervention measures, this article may play an important role in clinical prevention and treatment of POP after cardiovascular surgery.