[Dysphagia] Chlorhexidine, oral care and tube feeding

[eripley at yahoo.com (Irene Campbell-Taylor)]

,Oral Decontamination with Chlorhexidine Reduces the Incidence of Ventilator-associated Pneumonia American Journal of Respiratory and Critical Care Medicine Vol 173. pp. 1348-1355, (2006)Published ahead of print on April 7, 2006
  Mirelle Koeman, Andre J. A. M. van der Ven, Eelko Hak, Hans C. A. Joore, Karin Kaasjager, Annemarie G. A. de Smet, Graham Ramsay, Tom P. J. Dormans, Leon P. H. J. Aarts, Ernst E. de Bel, Willem N. M. Hustinx, Ingeborg van der Tweel, Andy M. Hoepelman and Marc J. M. Bonten 
   
  Rationale: Ventilator-associated pneumonia (VAP) is the most frequently occurring nosocomial infection associated with increased morbidity and mortality. Although oral decontamination with antibiotics reduces incidences of VAP, it is not recommended because of potential selection of antibiotic-resistant pathogens. We hypothesized that oral decontamination with either chlorhexidine (CHX, 2%) or CHX/colistin (CHX/COL, 2%/2%) would reduce and postpone development of VAP, and oral and endotracheal colonization. 
  Objectives: To determine the effect of oral decontamination with CHX or CHX/COL on VAP incidence and time to development of VAP. 
  Methods: Consecutive patients needing mechanical ventilation for 48 h or more were enrolled in a randomized, double-blind, placebo-controlled trial with three arms: CHX, CHX/COL, and placebo (PLAC). Trial medication was applied every 6 h into the buccal cavity. Oropharyngeal swabs were obtained daily and quantitatively analyzed for gram-positive and gram-negative microorganisms. Endotracheal colonization was monitored twice weekly. 
  Results: Of 385 patients included, 130 received PLAC, 127 CHX and 128 CHX/COL. Baseline characteristics were comparable. The daily risk of VAP was reduced in both treatment groups compared with PLAC: 65% (hazard ratio [HR] = 0.352; 95% confidence interval [CI], 0.160, 0. 791; p = 0.012) for CHX and 55% (HR = 0.454; 95% CI, 0.224, 0. 925; p = 0.030) for CHX/COL. CHX/COL provided significant reduction in oropharyngeal colonization with both gram-negative and gram-positive microorganisms, whereas CHX mostly affected gram-positive microorganisms. Endotracheal colonization was reduced for CHX/COL patients and to a lesser extent for CHX patients. No differences in duration of mechanical ventilation, intensive care unit stay, or intensive care unit survival could be demonstrated. 
  Conclusions: Topical oral decontamination with CHX or CHX/COL reduces the incidence of VAP
   
  ? BACKGROUND Decreasing the levels of bacteria in the oropharynx should reduce the prevalence of
  nosocomial pneumonia.
  ? OBJECTIVES To test the effectiveness of 0.12% chlorhexidine gluconate oral rinse in decreasing
  microbial colonization of the respiratory tract and nosocomial pneumonia in patients undergoing open
  heart surgery.
  ? METHODS A prospective, randomized, case-controlled clinical trial design was used. Peridex (0.12%
  chlorhexidine gluconate) was the experimental drug, and Listerine (phenolic mixture) was the control
  drug. A total of 561 patients undergoing aortocoronary bypass or valve surgery requiring cardiopulmonary
  bypass were randomized to an experimental (n = 270) or a control (n = 291) group. Nosocomial
  pneumonia was diagnosed by using the criteria established by the Centers for Disease Control and
  Prevention.
  ? RESULTS The overall rate of nosocomial pneumonia was reduced by 52% (4/270 vs 9/291; P=.21) in
  the Peridex-treated patients. Among patients intubated for more than 24 hours who had cultures that
  showed microbial growth (all pneumonias occurred in this group), the pneumonia rate was reduced by
  58% (4/19 vs 9/18; P = .06) in patients treated with Peridex. In patients at highest risk for pneumonia
  (intubated >24 hours, with cultures showing the most growth), the rate was 71% lower in the Peridex
  group than in the Listerine group (2/10 vs 7/10; P=.02).
  ? CONCLUSIONS Although rates of nosocomial pneumonia were lower in patients treated with Peridex
  than in patients treated with Listerine, the difference was significant only in those patients intubated
  more than 24 hours who had the highest degree of bacterial colonization. (American Journal of Critical
  Care. 2002;11:567-570)
  EFFECTIVENESS OF 0.12% CHLORHEXIDINE GLUCONATE
  ORAL RINSE IN REDUCING PREVALENCE OF NOSOCOMIAL
  PNEUMONIA IN PATIENTS UNDERGOING HEART SURGERY
  By Susan Houston, RN, PhD, CNAA, Paul Hougland, MD, Jacqueline J. Anderson, RN, MSN, Mark LaRocco,
  PhD, Virginia Kennedy, RN, MS, CIC, and Layne O. Gentry, MD. From St. Luke?s Episcopal Hospital (SH, PH,
  JJA, ML, VK, LOG) and Baylor College of Medicine (LOG), Houston, Tex.
   
   
  Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial infection and nonprohylactic systemic antibiotic use in patients undergoing heart surgery
  1996;109;1556-1561 Chest
  AJ DeRiso, 2nd, JS Ladowski, TA Dillon, JW Justice and AC Peterson
   
  Improving Oral Care in Patients Receiving Mechanical Ventilation 
  American Journal of Critical Care. 2005;14: 389-394
  By Constance J. Cutler, RN, MS, CIC and Nancy Davis, MA. From Clinical Excellence Department, Advocate Health Care, Oak Brook, Ill (CJC), and Medical Education and Research, Advocate Health Care, Park Ridge, Ill (ND). 
  ? Background Comprehensive oral care is an evidence-based prevention strategy to reduce the risk of ventilator-associated pneumonia in patients receiving mechanical ventilation. Until recently, no comprehensive guidelines or standards existed to define necessary tasks, methods, and frequency of oral care to provide patients with optimal results. 
  ? Objectives To observe current practice of, define best practice for, and measure compliance with standardized comprehensive oral care. 
  ? Methods This observational study was part of a larger research study performed at 5 acute care hospitals. Time blocks of 4 hours were randomized over 8 intensive care units and the 7 days of the week. Baseline data were collected before implementation of multifaceted education on an oral-cleansing protocol; interventional data were collected afterward. 
  ? Results Oral care practices were observed for 253 patients. During the baseline period, oral cleansing was primarily via suction swabs. Toothbrushing and moisturizing of the oral tissues were not observed. Only 32% of the patients had suctioning to manage oral secretions. During the interventional period, 33% of patients had their teeth brushed, 65% had swab cleansing, and 63% had a moisturizer applied to the oral mucosal tissues. A total of 61% had management of oral secretions; 38% had oropharyngeal suctioning via a special catheter. 
  ? Conclusions Implementation of an evidence-based oral cleansing protocol improved the care of patients receiving mechanical ventilation. Multifaceted education and implementation strategies motivated staff to increase oral care practices. 
   
  Pathogenic Colonization of Oral Flora in Frail Elderly Patients Fed by Nasogastric Tube or Percutaneous Enterogastric Tube The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58:M52-M55 (2003)
  Arthur Leibovitz1, Galina Plotnikov1, Beni Habot1, Mel Rosenberg2 and Rephael Segal1 
  1 Shmuel Harofe Hospital (affiliated with the Sackler Faculty of Medicine), Geriatric Medical Center, Beer-Yaakov, Israel.
2 Department of Oral Microbiology, Tel-Aviv University, Israel. 
  Background. Aspiration of infected oropharyngeal content is the main cause of aspiration pneumonia. This complication, mainly related to gram-negative bacteria, threatens percutaneous enterogastric tube as well as nasogastric tube (NGT) fed patients. The objective of this study was to examine the oral microbiota of tuboenterally fed patients and compare it with that of orally fed counterparts. 
  Methods. Patients were recruited for this study from six nursing and skilled nursing facilities with an overall number of 845 beds. Enrolled were 215 patients: Group 1 consisted of 78 patients on NGT feeding, Group 2 consisted of 57 patients on percutaneous enterogastric tube feeding, and Group 3 consisted of 80 patients fed orally who were from the same facilities. Cultures were performed by sampling the oropharynx of each subject in order to identify gram-negative bacteria and Staphylococcus aureus. 
  Results. A high prevalence of potentially pathogenic isolations was found in tuboenterally fed patients: 81% in Group 1 and 51% in Group 2, as compared with only 17.5% in Group 3 (p <.0001). Pseudomonas aeruginosa was cultured from 31% of the subjects in Group 1 and 10% of Group 2, but in none of Group 3 (p <.001). Klebsiella and Proteus were isolated mainly from the NGT fed patients (p <.003). No correlation was found between the time duration on tube feeding or the presence of residual dentition and pathogenic microbiota. 
  Conclusion. This study shows that tuboenteral feeding in elderly patients is associated with pathogenic colonization of the oropharynx. These findings are related to the risk of aspiration pneumonia and are compelling for the reevaluation of current oral cleansing procedures. 


Dr I Campbell-Taylor
Clinical Neuroscientist
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