Log in | Register

Impact of improvement in preoperative oral health on nosocomial pneumonia in a group of cardiac surgery patients: a single arm prospective intervention study

Eduardo H. Bergan| Bernardo R. Tura| Cristiane C. Lamas
Original
Volume 40, Issue 1 / January , 2014

Pages 23 - 31

Abstract

Purpose

To evaluate the effects of an oral health protocol on the incidence of postoperative pneumonia in patients submitted to coronary artery bypass grafting and to valve surgery.

Methods

All patients admitted to a public cardiac surgery hospital were examined by a dentist and had a thorough dentistry anamnesis and an intraoral exam focusing on teeth, gums, and tongue. Patients were taught how to brush their teeth and tongue and how to clean their jugal and palatal membranes. Chlorhexidine gluconate (CXG) 0.12 % oral rinse twice a day was used until surgery. Data on age, sex, comorbidities, oral evaluation, type of surgery, and development of pneumonia were obtained. Statistical analysis was done on these variables to evaluate the impact of the study protocol.

Results

A total of 226 patients were enrolled, 136 male (60.2 %). The median age was 59 years. There were 123 (54.4 %) patients with coronary artery disease and 103 (45.6 %) with valve disease. There were 18/226 (8 %) postoperative pneumonias (PP), nine in each group. Ten occurred in dentate patients and eight in edentulous ones. Oral health optimization was achieved in 208/226 (92 %) of patients in the preoperative period. The presence of tongue plaque (OR 17, P < 0.001) and of poor hygiene of the total superior dentures (OR 25, P < 0.001) in the preoperative period significantly increased the chance of PP. The use of CXG 0.12 % in the preoperative period (OR 0.06, P < 0.001) and on the day of surgery (OR 0.002, P < 0.001) was protective against PP. Mortality in patients without pneumonia was 9/208 (4.32 %) vs. 6/19 (33.3 %) in those with pneumonia. The presence of pneumonia increased the chances of death by 11 times (P < 0.001). The mean pneumonia rate in ICU in the 6 months before the study protocol was 32 per 1,000 ventilator-days, 24 during the 6-month intervention period, and 10 during the next 6 months following the study.

Conclusions

PP rates were reduced using a simple and efficient protocol of dental care that improved oral hygiene in the preoperative period of cardiac surgery patients.

Keywords

References

  1. Paju S, Scannapieco FA (2007) Oral biofilms, periodontitis, and pulmonary infections. Oral Dis 13:508–512
    • View reference on PubMed
    • View reference on publisher's website
  2. Hutchins K, Karrus G, Erwin J et al (2009) Ventilator-associated pneumonia and oral care: a successful quality improvement project. Am J Infect Control 37(7):590–597
    • View reference on PubMed
    • View reference on publisher's website
  3. American Thoracic Society, Infectious Diseases Society of America (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171:388–416. doi: 10.1164/rccm.200405-644ST
  4. Hortal J, Muñoz p, Cuerpo G et al (2009) Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe. Crit Care 13(3):R80
    • View reference on PubMed
    • View reference on publisher's website
  5. Craven DE (2000) Epidemiology of ventilator-associated pneumonia. Chest 117:1865–1875
  6. Garcia R (2005) A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions. Am J Infect Control 33:527–541
    • View reference on PubMed
    • View reference on publisher's website
  7. Drinka PJ, El-Solh AA (2010) The tongue, oral hygiene, and prevention of pneumonia in the institutionalized elderly. JAMDA 11(7):465–467
    • View reference on PubMed
  8. Abe S, Ishihara K, Adachi M et al (2008) Tongue-coating as risk indicator for aspiration pneumonia in edentate elderly. Arch Gerontol Geriatr 47:267–275
    • View reference on PubMed
    • View reference on publisher's website
  9. Scannapieco FA (2006) Pneumonia in nonambulatory patients. JADA 137:215–219
  10. Scannapieco FA, Genco RJ (1999) Association of periodontal infections with atherosclerotic and pulmonary diseases. J Periodontal Res 34:340–345
    • View reference on PubMed
    • View reference on publisher's website
  11. Berry AM, Davidson PM, Nicholson L et al (2011) Consensus based clinical guideline for oral hygiene in the critically ill. Intensive Crit Care Nurs 27:180–185
    • View reference on PubMed
    • View reference on publisher's website
  12. Halm MA, Armola R (2009) Effect of oral care on bacterial colonization and ventilator-associated pneumonia. Am J Crit Care 18:275–278
    • View reference on PubMed
    • View reference on publisher's website
  13. Dodd MJ, Dibble SL, Miaskowski C et al (2000) Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90(1):39–47
    • View reference on PubMed
    • View reference on publisher's website
  14. Blot S, Rello J, Vogelaers D (2011) What is new in the prevention of ventilator-associated pneumonia? Curr Opin Pulm Med 17:155–159
    • View reference on PubMed
    • View reference on publisher's website
  15. DMFT index. http://classof2011indexwikisite.wikispaces.com/DMFT+Index. Accessed May 2013
  16. Greene JC, Vermillion JR (1964) Simplified oral hygiene index. http://www.mah.se/CAPP/Methods-and-Indices/Oral-Hygiene-Indices/Simplified-Oral-Hygiene-Index-OHI-S/. Accessed May 2013
  17. Dos Santos PAT, Fortes TMV, Cabral MCB et al (2008) Influence of sexual hormones on periodontal tissues in hormonal contraceptives users. Revista de Periodontia 18(03):55–63
  18. CPITN index. http://classof2011indexwikisite.wikispaces.com/CPITN+Index. Accessed May 2013
  19. Ambjornsen E, Vulderhaug J, Norheim PW et al (1982) Assessment of an additive index for plaque accumulation on complete maxillary dentures. Acta Odontol Scand 40(4):203–208
    • View reference on PubMed
    • View reference on publisher's website
  20. Bass method. http://www.oralcareshop.com/bass-method.htm. Accessed May 2013
  21. Flanagan PG, Findlay GP, Magee JT et al (2000) The diagnosis of ventilator-associated pneumonia using non-bronchoscopic, non-directed lung lavages. Intensive Care Med 26:20–30
  22. Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveillance definition of healthcare-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36:309–332
    • View reference on PubMed
    • View reference on publisher's website
  23. Wilson W, Taubert KA, Gewitz M et al (2007) Prevention of infective endocarditis. Guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 116:1736–1754
    • View reference on PubMed
    • View reference on publisher's website
  24. Munro CL, Grap MJ, Elswick RK Jr et al (2006) Oral health status and development of ventilator-associated pneumonia: a descriptive study. Am J Crit Care 15:453–460
    • View reference on PubMed
  25. Jones DJ, Munro CL, Grap MJ (2011) Natural history of dental plaque accumulation in mechanically ventilated adults: a descriptive correlational study. Intensive Crit Care Nurs 27(6):299–304
    • View reference on PubMed
    • View reference on publisher's website
  26. Munro CL, Grap MJ, jones DJ et al (2009) Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care 18(5):428–438
    • View reference on PubMed
    • View reference on publisher's website
  27. Grap MJ, Munro CL, Hamilton VA et al (2011) Early, single chlorhexidine application reduces ventilator-associated pneumonia in trauma patients. Heart Lung 40(5):e115–e122
    • View reference on PubMed
    • View reference on publisher's website
  28. Chlebicki MP, Safdar N (2007) Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 35:595–602
    • View reference on PubMed
    • View reference on publisher's website
  29. Sona CS, Zack JE, Schallom ME et al (2009) The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. J Intensive Car Med 37(7):590–597
  30. Garcia R, Jendresky L, Colbert L et al (2009) Reducing ventilator-associated pneumonia through advanced oral-dental care: a 48-month study. Am J Crit Care 18(6):523–534
    • View reference on PubMed
    • View reference on publisher's website
  31. Fourrier F, Duvivier B, Boutigny H et al (1998) Colonization of dental plaque: a source of nosocomial infections in intensive care unit patients. Crit Care Med 26(2):301–308
    • View reference on PubMed
    • View reference on publisher's website
  32. Rello J, Lode h, Cornaglia G et al (2010) A European care bundle for prevention of ventilator-associated pneumonia. Intensive Care Med 36:773–780
  33. Tablan OC, Anderson IJ, Besser R et al (2004) Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 53:1–36
    • View reference on PubMed
  34. Caserta RA et al (2012) A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting. BMC Infect Dis 12:234
    • View reference on PubMed
    • View reference on publisher's website
  35. Alhazzani W et al (2013) Toothbrushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia. Crit Care Med 41:646–655
    • View reference on PubMed
    • View reference on publisher's website
  36. Martin B (2010) Oral care for patients at risk for ventilator-associated pneumonia. http://www.aacn.org/wd/practice/content/oral-care-practice-alert.pcms?menu=practice. Accessed May 2013
  37. Balamurugan E, Kanimozhi A, Kumeri G (2012) Effectiveness of chlorhexidine oral decontamination in reducing the incidence of ventilator associated pneumonia: a meta-analysis. BJMP 5(1):a512
  38. Shehabi Y et al (2013) Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med 39:910–918
  39. Sole ML, Byers JF, Ludy JE et al (2002) Suctioning techniques and airway management practices: pilot study and instrument evaluation. Am J Crit Care 11:363–368
    • View reference on PubMed
  40. Muscerede J et al (2011) Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis. Crit Care Med 39(8):1985–1991
    • View reference on publisher's website

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement