State of the ScienceA 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
Section snippets
Epidemiology and impact of nosocomial pneumonia
Health care-associated pneumonia (HAP) accounts for a significant portion of all infections acquired by patients after admission to hospitals and nursing homes. Pneumonia may compose up to 15% of all infections in hospitals8 and 13% to 48% of infections in nursing homes.9 Estimates are that 150,000 to 300,000 cases of nosocomial pneumonia in adults occur in hospitals alone each year.10 A large multicenter trial evaluating 10,038 patients in Europe indicated that pneumonia is the most common
Host defenses
Lung tissue is composed of a vast epithelial surface area at which the primary function is the exchange of gases. This function requires that the lung cells remain in continuous contact with the external environment, a condition that increases the risk of exposure to airborne microorganisms. These bacteria and other organisms may then invade the cell surfaces of either the upper or sterile lower respiratory tract, an initial inoculum that may signify the beginnings of infection. Normally, the
Anaerobes and respiratory tract infection
Aerobic bacteria constitute the majority of organisms causing pneumonia. Anaerobes, because of the difficulties associated in laboratory isolation, are often overlooked as causes of respiratory infection; however, they have been implicated in up to 35% of all nosocomial respiratory infection cases.98 Aspiration pneumonia in patients on mechanical ventilation is closely associated with anaerobic bacteria,99 a large group of organisms often implicated in the destruction of periodontal tissue.77
Surveying oral care practice
The importance of proper oral care in patients, particularly for intubated individuals, is not a recent notion.112, 113 Current critical care nursing manuals,114, 115, 116 as well as protocols issued by The American Association for Critical Care Nurses (AACN),117 advocate proper oral care using swabbing, toothbrushing, and suctioning of oral secretions. Despite the knowledge contained in these clinical sources on effective measures to reduce colonization in the oropharynx, the implementation of
Current recommendations and suggested interventions
Current recommendations from the CDC7 and the AACN117 published guidelines specifically addressing oral and dental care as it relates to the prevention of health care-associated pneumonia are summarized in Table 2, with categories in Appendix A. A review of published scientific literature indicates strong evidence of a link between bacterial colonization of the oropharynx and dental plaque and the occurrence of nosocomial pneumonia in community, long-term care, and hospital settings. More
Conclusion
The cumulative scientific evidence published to date strongly supports new interventions as part of a comprehensive oral and dental care plan that can very likely prevent nosocomial pneumonia. The oral cavity as a source of pathogens causing respiratory infection is underappreciated. Additional studies are needed to refine clinical practice and should address oral assessment, specific types of interventions, intervention frequency, maintenance of tissue integrity, and reduction of dental
References (180)
- et al.
Infection control in the ICU
Chest
(2001) - et al.
Nosocomial infections in U.S. hospitals, 1975-1976: estimated frequencies by selected characteristics of patients
Am J Med
(1981) - et al.
Nosocomial pneumonia: a multivariate analysis of risk and prognosis
Chest
(1988) - et al.
The effect of late-onset ventilator-associated pneumonia in determining patient mortality
Chest
(1995) - et al.
Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay
Am J Med
(1993) - et al.
Epidemiology and outcomes of ventilator-associated pneumonia in a large US database
Chest
(2002) - et al.
Pulmonary host defenses, implications for therapy
Clin Chest Med
(1999) - et al.
Gastric colonization by gram-negative bacilli and nosocomial pneumonia in the intensive care unit patient: evidence for causation
Chest
(1992) - et al.
Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery
Chest
(1996) - et al.
The stomach is not a source for colonization of the upper respiratory tract and pneumonia in ICU patients
Chest
(1994)
Controversies on diagnosis and prevention of ventilator-associated pneumonia
Diagn Microbiol Infect Dis
Leakage of fluid past the tracheal tube cuff in a bench top model
Br J Anaesth
Evaluation of a new design of tracheal tube cuff to prevent leakage of fluid to the lungs
Br J Anaesth
Aspiration pneumonia
Am J Surg
Contribution of endotracheal tubes to the pathogenesis of ventilator-associated pneumonia
J Hosp Infect
Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial therapy, and preventive strategies. A Consensus Statement
Am J Respir Crit Care Med
Epidemiology of nosocomial pneumonia: new perspectives on an old disease
Chest
The prevention of ventilator-associated pneumonia
N Eng J Med
Infection control in intensive care units and prevention of ventilator-associated pneumonia
Semin Respir Infect
Evidence-based airway management
Respir Care
Guideline for the Prevention of Healthcare-Associated Pneumonia, 2004. Centers for Disease Control and Prevention, Healthcare Infection Control Practices Advisory Committee
Nursing home-acquired pneumonia
Semin Respir Infect
Hospital acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and prevention strategies
Am J Resp Crit Care Med
The prevalence of nosocomial infection in intensive care units in Europe: results of the European Prevalence of infection in Intensive Care (EPIC) Study: EPIC International Advisory Committee
JAMA
Nosocomial infection rates in adult and pediatric intensive care units in the United States
Am J Med
National Nosocomial Infections Surveillance (NNIS) System Report. Centers for Disease Control and Prevention
Am J Infect Cont
Nosocomial infection and fatality in medical and surgical intensive care units
Arch Intern Med
Role of respiratory assistance device in endemic nosocomial pneumonia
Am J Med
Nosocomial infections in surgical patients in the United States, January 1986-June 1992. National Nosocomial Infections Surveillance (NNIS) System
Infect Control Hosp Epidemiol
Ventilator-associated pneumonia
Arch Intern Med
Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients
Ann Intern Med
Ventilator-associated pneumonia
Am J Resp Crit Care Med
Nosocomial pneumonia in patients receiving continuous mechanical ventilation: prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques
Ann Rev Respir Dis
Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients
Ann Rev Respir Dis
Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation
Am Rev Respir Dis
Ventilator-associated pneumonia: a multivariate analysis
JAMA
Risk factors for nosocomial pneumonia in critically ill trauma patients
Crit Care Med
Incidence and etiology of pneumonia acquired during mechanical ventilation
Crit Care Med
Pneumonia in intubated trauma patients: microbiology and outcomes
Am J Respir Crit Care Med
Effect of ventilator-associated pneumonia on mortality and morbidity
Am J Resp Crit Care Med
The attributable morbidity and mortality of ventilator-associated pneumonia in critically ill patients: The Canadian Critical Trials Group
Am J Resp Crit Care Med
High cost of nosocomial infections
Infect Control
Prospective payment and infection control
Infect Control
Incidence and nature of endemic and epidemic nosocomial infection
Analysis of factors related to the development of ventilator-associated pneumonia: use of existing databases
Am J Crit Care
Nosocomial respiratory infections
The normal microbial flora
N Eng J Med
Prevention of colonization and infection in critically ill patients: a prospective randomized study
Crit Care Med
Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections: a prospective randomized study
Intensive Med
Cited by (55)
The impact of tooth brushing versus tooth brushing and chlorhexidine application to avoid postoperative pneumonia in children
2019, American Journal of Infection ControlOral Health Interventions Using Chlorhexidine—Effects on the Prevalence of Oral Opportunistic Pathogens in Stroke Survivors: A Randomized Clinical Trial
2018, Journal of Evidence-Based Dental PracticeCitation Excerpt :In addition, it was noted that a large volume of aspiration may carry greater risks than a small volume of aspiration.14 Apart from the type and volume of aspiration, the presence of oral opportunistic pathogens in the frail and immunocompromised patients was associated with the increased risk of aspiration pneumonia.15 Studies have reported that interventions in oral hygiene are successful in reducing the incidence of aspiration pneumonia16 and improving oral health and oral health–related quality of life.17,18
Association of Unfinished Root Canal Treatments with the Risk of Pneumonia Hospitalization
2017, Journal of EndodonticsHealthcare-associated respiratory tract infection and colonization in an intensive care unit caused by Burkholderia cepacia isolated in mouthwash
2014, International Journal of Infectious DiseasesCitation Excerpt :Mouthwashes are used widely in patients undergoing mechanical ventilation. Such patients are highly vulnerable to pathogens that typically cause upper respiratory tract infections because of their inability to maintain the mucociliary and cough mechanisms that normally protect the lower respiratory tract.8 These bacteria have also contaminated many drug products, leading to public health concerns.
One evidence based protocol doesn't fit all: Brushing away ventilator associated pneumonia in trauma patients
2012, Intensive and Critical Care NursingVentilator-associated pneumonia: The potential critical role of emergency medicine in prevention
2012, Journal of Emergency MedicineCitation Excerpt :Oral flora change within the first 48 h of critical illness from the usual predominance of streptococci to more potentially pathogenic microbes, and these microorganisms have been hypothesized to contribute to VAP (19–22). Dental plaque, which may serve as a reservoir for potential VAP pathogens, also has been associated with nosocomial pneumonia (23–27). Although the use of a cuffed ETT is considered the gold standard of airway management and airway protection against large volume aspiration, this does not guarantee prevention of VAP, which is most often caused by aspiration of small volumes around the cuff (microaspiration).