Oropharyngeal Decontamination with Antiseptics to Prevent Ventilator-Associated Pneumonia: Rethinking the Benefits of Chlorhexidine

2017 ◽  
Vol 38 (03) ◽  
pp. 381-390 ◽  
Author(s):  
Michael Klompas
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Meta Analysis ◽  
Unit Length ◽  
Oral Care ◽  
Care Practice ◽  
Equal Weight ◽  
Ventilator Associated Pneumonia ◽  
Meta Analyses ◽  
Double Blinded

AbstractDaily oral care with chlorhexidine for mechanically ventilated patients is ubiquitous in contemporary intensive care practice. The practice is predicated upon meta-analyses suggesting that adding chlorhexidine to daily oral care regimens can reduce ventilator-associated pneumonia (VAP) rates by up to 40%. Close analysis, however, raises three concerns: (1) the meta-analyses are dominated by studies in cardiac surgery patients in whom average duration of mechanical ventilation is < 1 day and thus their risk of VAP is very different from other populations, (2) diagnosing VAP is subjective and nonspecific yet the meta-analyses gave equal weight to blinded and nonblinded studies, potentially biasing them in favor of chlorhexidine, and (3) there is circularity between diagnostic criteria for VAP and chlorhexidine; as an antiseptic, chlorhexidine may decrease the frequency of positive respiratory cultures but fewer cultures does not necessarily mean fewer pneumonias. It is therefore important to look at other outcomes for corollary evidence on whether or not oral chlorhexidine benefits patients. An updated meta-analysis restricted to double-blinded studies in noncardiac surgery patients showed no impact on VAP rates, duration of mechanical ventilation, or intensive care unit length of stay. Instead, there was a possible signal that oral chlorhexidine may increase mortality rates. Observational data have raised similar concerns. This article will review the theoretical basis for adding chlorhexidine to oral care regimens, delineate potential biases in randomized controlled trials comparing oral care regimens with and without chlorhexidine, explore the unexpected mortality signal associated with oral chlorhexidine, and provide practical recommendations.

scholarly journals Oral Care for Intensive Care Unit Patients Without Mechanical Ventilation: Protocol for a Systematic Review and Meta-Analysis

2020 ◽  
Author(s):  
Xiaoxia Tang ◽  
Yunxia Shen ◽  
Xuejiao Pan ◽  
Jianglong Liao ◽  
Yanfei Xu ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Nosocomial Pneumonia ◽  
Systematic Reviews ◽  
Meta Analysis ◽  
Oral Care ◽  
Significant Heterogeneity ◽  
Online Databases ◽  
Effect Model

Abstract BackgroundInfection is a common problem and a major cause of morbidity and mortality for patients in intensive care units (ICUs). Oral care has been found to reduce the risk of nosocomial pneumonia according to published meta-analysis, and has been recommended to improve the oral environment for the patients in ICUs. However, relatively little information is available about the effects of oral care in patients without ventilatory support in ICUs. Therefore, this study was designed to evaluate the effectiveness of oral care in preventing pneumonia in non-ventilated ICUs patients.MethodsThe literature source will be gained from eight databases including four Chinese online databases and four English online databases from their inception to December 31, 2020. Records obtained will be managed and screened via Endnote X7，a widely used reference management software. The duplicate literature will be removed. All literature will be selected in accordance with pre-established inclusion criteria by two independent review authors to obtain quality trials. The quality of the included records will be evaluated according to “Risk of table”, recommended by Cochrane Handbook for Systematic Reviews of Interventions. All the data will be extracted by one author and checked by another. If there is any disagreement, a final agreement will be reached with a third reviewer via consulting. The data obtained will be managed via Microsoft Excel. If there is missing data, the original authors will be emailed to ask for it. If enough data was collected, the data synthesis will be performed using Review Manager (RevMan5.3). Otherwise, only the qualitative analysis will be carried out. The overall effect will be estimated on oral care for intensive care unit patients without mechanical ventilation to prevent nosocomial pneumonia using random effect model or fixed effect model base on the heterogeneity results. The sources of heterogeneity will be performed using Meta-regression and subgroup analysis if there is significant heterogeneity. The funnel plot will be used to assess the publish bias, if there are enough records included. The Cochrane Handbook for Systematic Reviews of Interventions will be followed throughout the system evaluation process.ConclusionThis study will provide evidence of oral care for intensive care unit patients without mechanical ventilation to prevent nosocomial pneumonia.PROSPERO Research registration identifying numberCRD42020146932

Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation

2007 ◽  
Vol 16 (6) ◽  
pp. 552-562 ◽  
Author(s):  
Angela M. Berry ◽  
Patricia M. Davidson ◽  
Janet Masters ◽  
Kaye Rolls
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Randomized Controlled Trials ◽  
Oral Hygiene ◽  
Oral Care ◽  
Controlled Trials ◽  
Ventilator Associated Pneumonia ◽  
Intensive Care Patients ◽  
Randomized Controlled ◽  
Hygiene Practices

Background Oropharyngeal colonization with pathogenic organisms contributes to the development of ventilator-associated pneumonia in intensive care units. Although considered basic and potentially nonessential nursing care, oral hygiene has been proposed as a key intervention for reducing ventilator-associated pneumonia. Nevertheless, evidence from randomized controlled trials that could inform best practice is limited. Objective To appraise the peer-reviewed literature to determine the best available evidence for providing oral care to intensive care patients receiving mechanical ventilation and to document a research agenda for this important activity in optimizing patients’ outcomes. Methods Articles published from 1985 to 2006 in English and indexed in the CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, EMBASE, and DARE databases were searched by using the key terms oral hygiene, oral hygiene practices, oral care, mouth care, mouth hygiene, intubated, mechanically ventilated, intensive care, and critical care. Reference lists of retrieved journal articles were searched for publications missed during the primary search. Finally, the Google search engine was used to do a comprehensive search of the World Wide Web to ensure completeness of the search. The search strategy was verified by a health librarian. Results The search yielded 55 articles: 11 prospective controlled trials, 20 observational studies, and 24 descriptive reports. Methodological issues and the heterogeneity of samples precluded meta-analysis. Conclusions Despite the importance of providing oral hygiene to intensive care patients receiving mechanical ventilation, high-level evidence from rigorous randomized controlled trials or high-quality systematic reviews that could inform clinical practice is scarce.

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

2022 ◽  
Vol 11 (1) ◽  
Author(s):  
Xiaoxia Tang ◽  
Yunxia Shen ◽  
Xuejiao Pan ◽  
Jianglong Liao ◽  
Yanfei Xu ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Nosocomial Pneumonia ◽  
Systematic Reviews ◽  
Meta Analysis ◽  
Oral Care ◽  
Publication Date ◽  
Significant Heterogeneity ◽  
Effect Model

Abstract Background Infection is a common problem and a major cause of morbidity and mortality for patients in intensive care units (ICUs). According to published meta-analyses, oral care has been found to reduce the risk of nosocomial pneumonia, and has been recommended to improve the oral environment for patients in ICUs. However, relatively little information is available about the effects of oral care in patients without ventilatory support in ICUs. Therefore, this review proposes to evaluate the effectiveness of oral care in preventing pneumonia in non-ventilated ICU patients. Methods Eight databases will be searched for relevant literature, including four Chinese and four English online databases, from their inception to the protocol publication date. Records obtained will be managed and screened via Endnote X7. All literature will be selected following pre-established inclusion criteria by two independent review authors to obtain quality trials. The quality of the included records will be evaluated according to the “risk of bias table”, recommended by the Cochrane Handbook for Systematic Reviews of Interventions. All the data will be extracted by one author and checked by another. If there is any disagreement, a final agreement will be reached with a third reviewer via consultation. If there are missing data, the original authors will be emailed to ask for it. If enough data were collected, the data synthesis will be performed using Review Manager (RevMan5.3). Both a random effect model and a fixed effect model will be undertaken. A Bayesian meta-analysis will also be performed to estimate the magnitude of the heterogeneity variance and comparing it with the distribution using the WinBUGS software. Otherwise, the results will be reported narratively. The sources of heterogeneity will be determined using meta-regression and subgroup analysis if there is significant heterogeneity. A funnel plot will be used to assess publication bias if there are enough records included. The Cochrane Handbook for Systematic Reviews of Interventions will be followed throughout the system evaluation process. Conclusion This review will provide evidence of oral care for intensive care unit patients without mechanical ventilation to prevent nosocomial pneumonia. Trial registration PROSPERO Research registration identifying number: CRD42020146932

Analysis of diagnostic criteria for ventilator-associated pneumonia: a cohort study

2021 ◽  
Vol 74 (6) ◽  
Author(s):  
Caroline Gonçalves Pustiglione Campos ◽  
Aline Pacheco ◽  
Maria Dagmar da Rocha Gaspar ◽  
Guilherme Arcaro ◽  
Péricles Martim Reche ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Cohort Study ◽  
Intensive Care ◽  
Diagnostic Criteria ◽  
Statistical Tests ◽  
Significant Risk ◽  
Diagnostic Methods ◽  
Ventilator Associated Pneumonia

ABSTRACT Objectives: to analyze the diagnostic criteria for ventilator-associated pneumonia recommended by the Brazilian Health Regulatory Agency and the National Healthcare Safety Network/Centers for Disease Control and Prevention, as well as its risk factors. Methods: retrospective cohort study carried out in an intensive care unit throughout 12 months, in 2017. Analyses included chi-square, simple linear regression, and Kappa statistical tests and were conducted using Stata 12 software. Results: the sample was 543 patients who were in the intensive care unit and under mechanical ventilation, of whom 330 (60.9%) were men and 213 (39.1%) were women. Variables such as gender, age, time under mechanical ventilation, and oral hygiene proved to be significant risk factors for the development of ventilator-associated pneumonia. Conclusions: patients submitted to mechanical ventilation need to be constantly evaluated so the used diagnostic methods can be accurate and applied in an objective and standardized way in Brazilian hospitals.

Ventilator-Associated Pneumonia in a Pediatric Intensive Care Unit in Saudi Arabia: A 30-Month Prospective Surveillance

2004 ◽  
Vol 25 (9) ◽  
pp. 753-758 ◽  
Author(s):  
Maha Almuneef ◽  
Ziad A. Memish ◽  
Hanan H. Balkhy ◽  
Hala Alalem ◽  
Abdulrahman Abutaleb
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Saudi Arabia ◽  
Intensive Care ◽  
Antibiotic Therapy ◽  
Pediatric Intensive Care ◽  
Ventilator Associated Pneumonia ◽  
Prospective Surveillance ◽  
The Mean ◽  
Prior Antibiotic Therapy

AbstractObjective:To describe the rate, risk factors, and outcome of ventilator-associated pneumonia (VAP) in pediatric patients.Methods:This prospective surveillance study of VAP among all patients receiving mechanical ventilation for 48 hours or more admitted to a pediatric intensive care unit (PICU) in Saudi Arabia from May 2000 to November 2002 used National Nosocomial Infections Surveillance (NNIS) System definitions.Results:Three hundred sixty-one eligible patients were enrolled. Most were Saudi with a mean age of 28.6 months. Thirty-seven developed VAP. The mean VAP rate was 8.87 per 1,000 ventilation-days with a ventilation utilization rate of 47%. The mean duration of mechanical ventilation was 21 days for VAP patients and 10 days for non-VAP patients. The mean PICU stay was 34 days for VAP patients and 15 days for non-VAP patients. Among VAP patients, Pseudomonas aeruginosa was the most common organism, followed by Staphylococcus aureus. Other gram-negative organisms were also encountered. There was no significant difference between VAP and non-VAP patients regarding mortality rate. Witnessed aspiration, reintubation, prior antibiotic therapy, continuous enteral feeding, and bronchoscopy were associated with VAP. On multiple logistic regression analysis, only prior antibiotic therapy, continuous enteral feeding, and bronchoscopy were independent predictors of VAP.Conclusions:The mean VAP rate in this hospital was higher than that reported by NNIS System surveillance of PICUs. This study has established a benchmark for future studies of VAP in the pediatric intensive care population in Saudi Arabia. Additional studies from the region are necessary for comparison and development of preventive measures.

Improving Adherence to a Mechanical Ventilation Weaning Protocol for Critically Ill Adults: Outcomes After an Implementation Program

2006 ◽  
Vol 15 (3) ◽  
pp. 299-309 ◽  
Author(s):  
Suzanne E. McLean ◽  
Louise A. Jensen ◽  
Dallas G. Schroeder ◽  
Noel R. T. Gibney ◽  
Neil M. Skjodt
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Multidisciplinary Team ◽  
Safety Climate ◽  
Ventilator Associated Pneumonia ◽  
Implementation Program ◽  
General Systems ◽  
Ventilation Weaning ◽  
Mechanical Ventilation Weaning

• Background Despite multiple reminders, education sessions, and multidisciplinary team involvement, adherence to an evidence-based mechanical ventilation weaning protocol had been less than 1% in a general systems intensive care unit since implementation. • Objective To assess the effectiveness of using an implementation program, the Model for Accelerating Improvement, to improve adherence and clinical outcomes after restarting a mechanical ventilation weaning protocol in an adult general systems intensive care unit. • Methods A prospective comparative design, before and after implementation of the Model for Accelerating Improvement, was used with a consecutive sample of 129 patients and 112 multidisciplinary team members. Clinical outcomes were rate of unsuccessful extubations, rate of ventilator-associated pneumonia, and duration of mechanical ventilation; practice outcomes were staff’s understanding of the mechanical ventilation weaning protocol, perceptions of the practice safety climate, and adherence to the weaning protocol. • Results After the intervention, the rate of unsuccessful extubations decreased, and staff’s understanding of and adherence to the weaning protocol increased significantly. The rate of ventilator-associated pneumonia, duration of mechanical ventilation, and staff’s perceptions of the practice safety climate did not change significantly. • Conclusion Implementing the Model for Accelerating Improvement improved understanding of and adherence to protocol-directed weaning and reduced the rate of unsuccessful extubations.

Rotational Bed Therapy to Prevent and Treat Respiratory Complications: A Review and Meta-Analysis

2007 ◽  
Vol 16 (1) ◽  
pp. 50-61 ◽  
Author(s):  
David R. Goldhill ◽  
Michael Imhoff ◽  
Barbara McLean ◽  
Carl Waldmann
Keyword(s):  
Mechanical Ventilation ◽  
Randomized Controlled Trials ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Convincing Evidence ◽  
Controlled Trials ◽  
Respiratory Complications ◽  
Randomized Controlled ◽  
Meta Analyses

• Background Immobility is associated with complications involving many body systems. • Objective To review the effect of rotational therapy (use of therapeutic surfaces that turn on their longitudinal axes) on prevention and/or treatment of respiratory complications in critically ill patients. • Methods Published articles evaluating prophylaxis and/or treatment were reviewed. Prospective randomized controlled trials were assessed for quality and included in meta-analyses. • Results A literature search yielded 15 nonrandomized, uncontrolled, or retrospective studies. Twenty prospective randomized controlled trials on rotational therapy were published between 1987 and 2004. Various types of beds were studied, but few details on the rotational parameters were reported. The usual control was manual turning of patients by nurses every 2 hours. One animal investigation and 12 clinical trials addressed the effectiveness of rotational therapy in preventing respiratory complications. Significant benefits were reported in the animal study and 4 of the trials. Significant benefits to patients were reported in 2 of another 4 studies focused on treatment of established complications. Researchers have examined the effects of rotational therapy on mucus transport, intrapulmonary shunt, hemodynamic effects, urine output, and intracranial pressure. Little convincing evidence is available, however, on the most effective rotation parameters (eg, degree, pause time, and amount of time per day). Meta-analysis suggests that rotational therapy decreases the incidence of pneumonia but has no effect on duration of mechanical ventilation, number of days in intensive care, or hospital mortality. • Conclusions Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation.

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