Oral Health and Hopsital Acquired Pneumonia Elderly Patients Review Jdh
Highlights
- •
At that place is considerable heterogeneity in the written report design, interventions, methods and definitions used in NV-HAP studies.
- •
Improving oral care, increased mobility or motility and dysphagia management announced to be key strategies in reducing NV-HAP.
- •
Farther research in a infirmary setting, using robust designs are needed.
Abstract
Groundwork
Signal prevalence studies identify that pneumonia is the about common healthcare associated infection. Still, non-ventilator associated healthcare associated pneumonia (NV-HAP) is both underreported and understudied. Most research conducted to appointment, focuses on ventilator associated pneumonia. We conducted a systematic review, to provide the latest evidence for strategies to reduce NV-HAP and describe the methodological approaches used.
Methods
Nosotros performed a systematic search to place enquiry exploring and evaluating NV-HAP preventive measures in hospitals and aged-care facilities. The electronic database Medline was searched, for peer-reviewed articles published between 1st Jan 1998 and 31st August 2018. An assessment of the study quality and risk of bias of included articles was conducted using the Newcastle–Ottawa Scale.
Results
The literature search yielded 1551 articles, with 15 articles meeting the inclusion criteria. The bulk of strategies for NV-HAP prevention focussed on oral care (n = nine). Three studies evaluated a form of concrete activity, such equally passive movements, ii studies used dysphagia screening and management; and another study evaluated condom antibiotics. Most studies (north = 12) were conducted in a infirmary setting. Half-dozen of the fifteen studies were randomised controlled trials.
Conclusion
There was considerable heterogeneity in the included studies, including the type of intervention, study pattern, methods and definitions used to diagnose the NV-HAP. To engagement, interventions to reduce NV-HAP announced to exist based broadly on the themes of improving oral care, increased mobility or motion and dysphagia management.
Keywords
- Infection control
- Healthcare-associated pneumonia
- Nursing intendance
- Systematic review
Introduction
In recent years, there have been numerous initiatives to reduce certain healthcare-associated infections (HAIs), such as bloodstream infections [
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], this infection has received little attention to appointment.
Indicate prevalence studies (PPS) in Europe and the Usa highlight the blazon and proportion of unlike HAIs. Data from Europe identified HAP as the virtually frequent HAI in prevalence studies conducted in England, Northern Ireland, Scotland, Wales [
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], the two subcategories of HAP. A mutual definition of VAP is where a case of pneumonia where the patient is on mechanical ventilation for >2 calendar days on the date of event and the ventilator was in place on the engagement of event or the day earlier, other cases beingness considered NV-HAP [
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While the impact of both VAP and NV-HAP on healthcare services and patients is meaning, bear witness suggests that NV-HAP occurs more often, is associated with higher healthcare costs and is every bit as dangerous every bit VAP [
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,
]. Withal, NV-HAP is both underreported and understudied with well-nigh research conducted on VAP, thereby prompting recent calls for an urgent need to prioritise research on NV-HAP [
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Risk factors for the evolution of NV-HAP are quite varied and like to those for HAP in general [
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14
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- Robertson T.
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,
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Methods
A systematic review to place research exploring and evaluating NV-HAP preventive measures in hospitals and aged-care facilities was undertaken. Reporting of this systematic review complied with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [
].
Search strategy
Nosotros performed a systematic search of the literature. Using the key words stated beneath, we searched the electronic database Medline and reviewed the reference lists of eligible articles to place whatever additional relevant articles. The electronic search was limited to articles published between 1st January 1998 and 31st August 2018 in peer-reviewed journals, with no limits placed on language. A combination of Medical Subject Heading (MeSH) and gratuitous-text terms was used, based on a prior review of the literature [
].
The get-go search involved the following terms: ('pneumonia' OR 'respiratory tract infection' OR 'respiratory infection') AND ('nosocomial' OR 'hospital-caused' OR 'healthcare associated' OR 'healthcare-associated') AND ('prevention'). We performed an additional search and combined this with the results from the previous search.
The keywords used in the second search were ('pneumonia' OR 'respiratory tract infection' OR 'respiratory infection') AND ('nosocomial' OR 'hospital-acquired' OR 'healthcare associated' OR 'healthcare-associated') AND.
- ○
'paw hygiene' OR 'hand washing' OR
- ○
'oral intendance' OR 'oral hygiene' OR 'oral decontamination' OR 'oral health' OR 'mouthwashes'
- ○
'bed position' OR 'caput position' OR 'body position' OR 'bed residuum' OR 'bed protocol'
- ○
'mobilization' OR 'mobility' OR 'motility' OR 'physical action' OR 'physiotherapy'
- ○
'dysphagia' OR 'swallowing' OR 'swallowing disorder' OR 'aspiration' OR 'aspirative'
- ○
'viral infection' OR 'viral' OR 'virus' OR 'flu'
- ○
'stress bleeding prophylaxis' OR 'gastric' OR 'gastric protection' OR 'acid-suppressive therapy' OR 'acid-suppressive' OR 'proton pump inhibitor' OR 'omeprazole' OR 'ranitidine'
Pick criteria
The inclusion criteria were all randomised controlled trials and observational studies (accomplice, case control, observational, cross exclusive or case/short reports) that examined measures (excluding vaccination and systematic antimicrobial therapy) to reduce HAP in hospitals and anile-care facilities. Just studies examining developed populations were included. Studies that did not analyse the effect of any prevention mensurate were initially included just after removed for sub-analysis. Exclusion criteria were studies examining VAP, all grey literature, non-peer-reviewed literature, reviews, editorials and commentaries.
Definitions
For the purpose of this systematic review, we used the following definitions:
- •
'Healthcare-associated infection' refers to any infection as defined or accustomed by the authors as beingness healthcare-associated, infirmary-acquired or nosocomial.
- •
'Measure' refers to interventions, clinical practise or policy. It excludes systematic antimicrobial treatment and vaccination measures.
- •
We accepted the definitions and application of defining pneumonia every bit stated in the paper.
Written report selection
Nosotros examined and assessed the titles and abstracts of all the publications identified in the electronic database for relevance and appropriateness to the review question and excluded those that were irrelevant. Of the remaining articles, we reviewed the total texts to assess their further eligibility. Articles accounted to accept information relevant to the systematic review were included. Trained research assistants performed the study pick process and other stages of the review. Ten percent of the original articles were cross-checked with the written report eligibility criteria by two of the research assistants. In addition, an experienced enquiry member randomly selected x% of the original manufactures retrieved in the initial search and reviewed them as a cantankerous-check against the study eligibility criteria. Two members of the research team resolved any discrepancies that were observed in the application of either the inclusion or the exclusion criteria.
Data extraction
For each eligible study, the post-obit information were extracted using a data extraction form developed in Excel (Microsoft, USA): author(south); year of publication; country of study; written report pattern; study population; sample; setting; result measures; results for both the control and intervention groups, and conclusions. All data extracted were cantankerous-checked by a second member of the team. We did not attempt to contact the authors of papers that contained missing data or unclear information.
Risk of bias
An assessment of the written report quality and hazard of bias in the manufactures included in the review was conducted using the Newcastle–Ottawa Calibration [
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Data assay
Extracted information from the included studies were synthesised and summarised in evidence tables. Given the significant heterogeneity in the included studies, we did not attempt to acquit a meta-assay.
Results
Overview
The literature search yielded 1551 articles. Of these, 56 articles remained for a total text review following a review of the titles and abstracts and the exclusion of duplicates. After screening the 56 articles against the study's inclusion and exclusion criteria, we excluded 43 articles either considering they did non report on NV-HAP, they did not evaluate the impact of an intervention, or they were reviews. With the add-on of three eligible articles that were known to the research team from transmission searches (i from an excluded review, two from references lists of included articles), 15 articles met the inclusion criteria and were included in the final systematic review (Fig. 1).
In this review of literature, we identified 15 studies that involved an intervention aimed at reducing NV-HAP. There was considerable heterogeneity in these studies, including the type of intervention, study blueprint, methods and definitions used to diagnose the NV-HAP. To appointment, interventions to reduce NV-HAP appear to be based broadly on the themes of improving oral care, increased mobility or move and dysphagia management.
Report characteristics
Table i provides an overview of the xv studies included in the review. The bulk of strategies for NV-HAP prevention focussed on oral intendance (northward = nine), with four oral intendance approaches using dental professionals [
,
29
- Bellissimo-Rodrigues W.T.
- Menegueti M.Yard.
- Gaspar G.G.
- Nicolini E.A.
- Auxiliadora-Martins M.
- Basile-Filho A.
- et al.
Effectiveness of a dental care intervention in the prevention of lower respiratory tract nosocomial infections amongst intensive intendance patients: a randomized clinical trial.
- Crossref
- PubMed
- Scopus (27)
- Google Scholar
,
,
]. Three studies evaluated a class of concrete activity, such equally passive movements [
32
- Boden I.
- Skinner Due east.H.
- Browning L.
- Reeve J.
- Anderson L.
- Hill C.
- et al.
Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: businesslike, double blinded, multicentre randomised controlled trial.
- Crossref
- PubMed
- Scopus (107)
- Google Scholar
,
,
]; two studies used dysphagia screening and management [
35
- Schrock J.W.
- Lou Fifty.
- Ball B.A.W.
- Van Etten J.
The apply of an emergency department dysphagia screen is associated with decreased pneumonia in acute strokes.
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,
36
- Titsworth W.Fifty.
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- Fullerton A.
- Hester J.
- Guin P.
- Waters K.F.
- et al.
Prospective quality initiative to maximize dysphagia screening reduces infirmary-acquired pneumonia prevalence in patients with stroke.
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]; and another study evaluated prophylactic antibiotics [
[37]
- Johansen North.J.
- Hahn C.H.
Prophylactic antibiotics at the time of tracheotomy lowers the incidence of pneumonia.
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]. Almost studies (n = 12) were conducted in a hospital setting. Six of the fifteen studies were randomised controlled trials.
Table one Studies included in the review.
| Author, Year | Design | Sample | Setting | Wide intervention strategy | Meaning change in pneumonia |
|---|---|---|---|---|---|
| Adachi et al., 2002 [28]
Effect of professional person oral health care on the elderly living in nursing homes.
| RCT | 141 | Nursing home | Oral care (professional) | Yeah |
| Bellisimo-Rodrigues et al., 2014 [29]
Effectiveness of a dental care intervention in the prevention of lower respiratory tract nosocomial infections among intensive care patients: a randomized clinical trial.
| RCT | 254 | Infirmary (Intensive Intendance Unit) | Oral care (professional) | YES |
| Boden et al., 2018 [32]
Preoperative physiotherapy for the prevention of respiratory complications afterward upper abdominal surgery: businesslike, double blinded, multicentre randomised controlled trial.
| RCT | 441 | Hospital | Physical activity | YES |
| Bouringault et al., 2010 [30]
Impact of bucco-dental healthcare on the prevention of pneumonia in geriatrics: a cluster-randomised trial.
| RCT | 2513 | Nursing home | Oral care (professional) | NO |
| Chen et al., 2016 [40]
Prospective observational report to compare oral topical metronidazole versus 0.2% chlorhexidine gluconate to prevent nosocomial pneumonia.
| Cohort | 873 | Hospital (Intensive Care Unit) | Oral care | YES |
| Cuesy et al., 2010 [33]
Reduction in the incidence of poststroke nosocomial pneumonia by using the "turn-mob" program.
| RCT | 223 | Infirmary | Physical activeness | YES |
| Johansen et al., 2016 [37]
Prophylactic antibiotics at the fourth dimension of tracheotomy lowers the incidence of pneumonia.
| Cohort | 88 | Hospital (Ear, Nose and Throat Department) | Prophylactic antibiotics | YES |
| McNally et al., 2018 [38]
Oral care clinical trial to reduce non-intensive care unit, infirmary-caused pneumonia: lessons for future enquiry.
| Quasi-experimental | 2891 | Hospital (non-ICU) | Oral care | NO |
| Quinn et al., 2014 [fourteen]
Bones nursing care to prevent nonventilator infirmary-caused pneumonia.
| Quasi-experimental | Infirmary | Oral care | Decrease+ | |
| Robertson et al., 2013 [20]
Oral intensity: reducing not-ventilator-associated infirmary-acquired pneumonia in care-dependent, neurologically dumb patients.
| Quasi-experimental | 85 | Hospital (acute neurosurgical unit of measurement) | Oral intendance | YES |
| Schrock et al., 2018 [35]
The use of an emergency department dysphagia screen is associated with decreased pneumonia in acute strokes.
| Cohort | 2372 | Hospital | Dysphagia screen | YES |
| Stolbrink et al., 2014 [34]
The Early on Mobility Bundle: a simple enhancement of therapy which may reduce incidence of infirmary-acquired pneumonia and length of hospital stay.
| Quasi-experimental | 156 | Hospital (respiratory and elderly wards) | Physical activeness | YES |
| Titsworth et al., 2013 [36]
Prospective quality initiative to maximize dysphagia screening reduces hospital-acquired pneumonia prevalence in patients with stroke.
| Cohort | 2334 | Hospital | Dysphagia screen | YES |
| Wagner et al., 2016 [39]
Adventure of stroke-associated pneumonia and oral hygiene.
| Cohort | 1656 | Hospital | Oral intendance | Aye |
| Yoneyama et al., 2012 [31]
Oral intendance reduces pneumonia in older patients in nursing homes.
| RCT | 366 | Nursing Home | Oral care (professional) | NO |
Note: + significance values not provided.
- Open table in a new tab
Hazard of bias assessment
We undertook a risk of bias assessment on the 15 studies included in the review. The maximum star rating using the Newcastle–Ottawa Scale is 9 stars. Iv studies received a star rating of viii [
,
36
- Titsworth Due west.Fifty.
- Abram J.
- Fullerton A.
- Hester J.
- Guin P.
- Waters M.F.
- et al.
Prospective quality initiative to maximize dysphagia screening reduces infirmary-caused pneumonia prevalence in patients with stroke.
- Crossref
- PubMed
- Scopus (72)
- Google Scholar
,
37
- Johansen N.J.
- Hahn C.H.
Condom antibiotics at the time of tracheotomy lowers the incidence of pneumonia.
- Google Scholar
,
38
- McNally E.
- Krisciunas G.P.
- Langmore Due south.E.
- Crimlisk J.T.
- Pisegna J.M.
- Massaro J.
Oral intendance clinical trial to reduce not-intensive care unit, hospital-acquired pneumonia: lessons for future research.
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], six studies received a rating of seven [
20
- Robertson T.
- Carter D.
Oral intensity: reducing not-ventilator-associated hospital-caused pneumonia in care-dependent, neurologically impaired patients.
- PubMed
- Google Scholar
,
29
- Bellissimo-Rodrigues W.T.
- Menegueti M.G.
- Gaspar G.G.
- Nicolini E.A.
- Auxiliadora-Martins Chiliad.
- Basile-Filho A.
- et al.
Effectiveness of a dental intendance intervention in the prevention of lower respiratory tract nosocomial infections among intensive care patients: a randomized clinical trial.
- Crossref
- PubMed
- Scopus (27)
- Google Scholar
,
32
- Boden I.
- Skinner E.H.
- Browning Fifty.
- Reeve J.
- Anderson L.
- Hill C.
- et al.
Preoperative physiotherapy for the prevention of respiratory complications subsequently upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial.
- Crossref
- PubMed
- Scopus (107)
- Google Scholar
,
,
,
39
- Wagner C.
- Marchina S.
- Deveau J.A.
- Frayne C.
- Sulmonte Thousand.
- Kumar Due south.
Risk of stroke-associated pneumonia and oral hygiene.
- Google Scholar
] and five studies received a rating of v or less [
14
- Quinn B.
- Baker D.L.
- Cohen S.
- Stewart J.L.
- Lima C.A.
- Parise C.
Basic nursing care to prevent nonventilator hospital-caused pneumonia.
- Google Scholar
,
,
,
35
- Schrock J.W.
- Lou L.
- Brawl B.A.W.
- Van Etten J.
The use of an emergency department dysphagia screen is associated with decreased pneumonia in acute strokes.
- Google Scholar
,
40
- Chen Y.
- Mao E.‐Q.
- Yang Y.‐J.
- Zhao S.‐Y.
- Zhu C.
- Wang X.‐F.
- et al.
Prospective observational written report to compare oral topical metronidazole versus 0.2% chlorhexidine gluconate to prevent nosocomial pneumonia.
- Google Scholar
]. Table ii provides an overview of the risk of bias assessment for each study.
Table 2 Adventure of bias cess.
| Get-go Author | Year | Elements of Newcastle–Ottawa Scale | |||
|---|---|---|---|---|---|
| Selection (0–4) | Comparability (0–2) | Exposure (0–3) | Full stars | ||
| Adachi | 2002 | iv | 0 | 0 | four |
| Bellisimo-Rodrigues | 2014 | 2 | ii | 3 | 7 |
| Boden | 2018 | 2 | 2 | three | 7 |
| Bourigaulta | 2010 | 4 | 1 | 0 | 5 |
| Chen | 2016 | 3 | 0 | 2 | 5 |
| Cuesy | 2010 | three | 1 | 3 | 7 |
| Johansen | 2016 | 3 | 2 | iii | 8 |
| McNally | 2018 | 3 | 2 | 3 | 8 |
| Quinn | 2014 | 2 | 0 | iii | 5 |
| Robertson | 2013 | 4 | 0 | 3 | 7 |
| Schrock | 2018 | 3 | 0 | 2 | 5 |
| Stolbrink | 2014 | iii | 2 | 2 | seven |
| Titsworth | 2013 | 4 | 2 | ii | eight |
| Wagner | 2016 | iii | 2 | ii | 7 |
| Yoneyama | 2002 | 4 | 1 | 3 | viii |
- Open tabular array in a new tab
Oral intendance and NV-HAP prevention
Nine studies in this review involved an oral intendance intervention to reduce the incidence of NV-HAP. Four of the nine studies involved professional oral care, such as oral care provided by a dentist or hygienist. All of these studies were randomised controlled studies [
,
29
- Bellissimo-Rodrigues W.T.
- Menegueti Yard.G.
- Gaspar Yard.Yard.
- Nicolini E.A.
- Auxiliadora-Martins K.
- Basile-Filho A.
- et al.
Effectiveness of a dental care intervention in the prevention of lower respiratory tract nosocomial infections among intensive care patients: a randomized clinical trial.
- Crossref
- PubMed
- Scopus (27)
- Google Scholar
,
,
], and three of them were performed in nursing homes [
,
,
]. The remainder of the studies (due north = five), did non use professional dental intendance every bit part of the oral care intervention [
xiv
- Quinn B.
- Baker D.Fifty.
- Cohen South.
- Stewart J.L.
- Lima C.A.
- Parise C.
Bones nursing care to prevent nonventilator infirmary-caused pneumonia.
- Google Scholar
,
20
- Robertson T.
- Carter D.
Oral intensity: reducing non-ventilator-associated hospital-acquired pneumonia in care-dependent, neurologically impaired patients.
- PubMed
- Google Scholar
,
38
- McNally Eastward.
- Krisciunas G.P.
- Langmore Southward.East.
- Crimlisk J.T.
- Pisegna J.Thou.
- Massaro J.
Oral care clinical trial to reduce non-intensive intendance unit, hospital-acquired pneumonia: lessons for future research.
- Google Scholar
,
39
- Wagner C.
- Marchina S.
- Deveau J.A.
- Frayne C.
- Sulmonte G.
- Kumar Due south.
Take chances of stroke-associated pneumonia and oral hygiene.
- Google Scholar
,
twoscore
- Chen Y.
- Mao E.‐Q.
- Yang Y.‐J.
- Zhao South.‐Y.
- Zhu C.
- Wang Ten.‐F.
- et al.
Prospective observational study to compare oral topical metronidazole versus 0.2% chlorhexidine gluconate to prevent nosocomial pneumonia.
- Google Scholar
]. None of these five studies used a randomised controlled design.
Non-professional oral care
There was considerable heterogeneity among interventions in the studies that involved routine oral care (i.e. non-professional dental care). No two studies had the same intervention, and where an clarified was used every bit role of oral care, the type of antiseptic differed betwixt studies. The interventions included: oral intendance kits that contained an antiseptic (cetylpyridinium chloride and ane.5% hydrogen peroxide) [
[39]
- Wagner C.
- Marchina South.
- Deveau J.A.
- Frayne C.
- Sulmonte Thou.
- Kumar S.
Risk of stroke-associated pneumonia and oral hygiene.
- Google Scholar
]; oral care by swabbing with an antiseptic (chlorhexidine gluconate vs. metronidazole) [
[40]
- Chen Y.
- Mao E.‐Q.
- Yang Y.‐J.
- Zhao South.‐Y.
- Zhu C.
- Wang Ten.‐F.
- et al.
Prospective observational study to compare oral topical metronidazole versus 0.two% chlorhexidine gluconate to prevent nosocomial pneumonia.
- Google Scholar
]; increased volume of oral care and the use of an antiseptic (0.05% cetylpyridinium chloride) [
[38]
- McNally E.
- Krisciunas Thou.P.
- Langmore South.E.
- Crimlisk J.T.
- Pisegna J.M.
- Massaro J.
Oral care clinical trial to reduce non-intensive care unit of measurement, infirmary-caused pneumonia: lessons for future research.
- Google Scholar
]; oral care kits and the use of a toothbrush containing sodium bicarbonate and an antiseptic (antiseptic unspecified) [
[fourteen]
- Quinn B.
- Baker D.L.
- Cohen Southward.
- Stewart J.L.
- Lima C.A.
- Parise C.
Basic nursing care to forbid nonventilator infirmary-acquired pneumonia.
- Google Scholar
]; and moisturiser, toothbrushes and oral swabs impregnated with sodium bicarbonate and an clarified rinse (i.5% hydrogen peroxide) [
[20]
- Robertson T.
- Carter D.
Oral intensity: reducing not-ventilator-associated infirmary-acquired pneumonia in care-dependent, neurologically impaired patients.
- PubMed
- Google Scholar
]. The outcomes from the oral care interventions were largely associated with a reduction in NV-HAP (Table 3).
Table 3 Summary of findings involving oral care and healthcare associated pneumonia.
| Study (first writer) | Outcome | Intervention (northward) | Control (n) | Comments | ||
|---|---|---|---|---|---|---|
| Consequence | Full | Event | Total | |||
| Professional dental care | ||||||
| Adachi | Fatal aspiration pneumonia | 2 | 40 | 8 | 48 | Significant reduction (p < 0.05). Original sample = 141, participants lost to follow-up. Observed over 24 calendar month period. |
| Bellisimo-Rodrigues | Pneumonia in not-ventilated patients | 0 | 127 | one | 127 | No cases during intervention. 294 sample, 40 excluded as died or discharged from ICU within 48 h. Pneumonia in non-ventilated patients was secondary issue. |
| Yoneyama | Pneumonia | 21 | 184 | 34 | 182 | Significant reduction (p < 0.05). 51 participants excluded from analysis considering they died from causes other than pneumonia during follow-up. |
| Fatal pneumonia | 14 | 184 | thirty | 182 | Significant reduction (p < 0.05) | |
| Bourigault | Patients with pneumonia | 93 | 868 | 203 | 1645 | No difference |
| Fatal pneumonia | 15 | 868 | 26 | 1645 | No difference | |
| Non-professional dental care | ||||||
| Chen | Hospital caused pneumonia | 84 | 661 | 44 | 212 | Pregnant reduction (p < 0.05) |
| McNally | Hospital caused pneumonia | 25 | 1403 | 26 | 1487 | No difference |
| Quinn | Infirmary acquired pneumonia | Unclear | Unclear | Unclear | Unclear | Incidence decreased from 0.49 to 0.3 per k patient days (38.8%). |
| Robertson | Hospital acquired pneumonia | 2 | 32 | 13 | 51 | Significant reduction (p < 0.05) |
| Wagner | Hospital acquired pneumonia (post-stroke) | 98 | 949 | 99 | 707 | Significant reduction (p < 0.05) |
Annotation: The raw numerator and denominator information from this study in the pre and mail intervention phases are non able to exist extracted from this study. No confident intervals are provided around the incidence rates.
- Open tabular array in a new tab
Professional oral intendance
Four studies involved the utilize of a dentist or dental hygienist in the delivery of oral care [
,
29
- Bellissimo-Rodrigues W.T.
- Menegueti M.Chiliad.
- Gaspar Yard.K.
- Nicolini East.A.
- Auxiliadora-Martins M.
- Basile-Filho A.
- et al.
Effectiveness of a dental intendance intervention in the prevention of lower respiratory tract nosocomial infections among intensive care patients: a randomized clinical trial.
- Crossref
- PubMed
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- Google Scholar
,
,
]. The interventions in the studies included.
- •
Dental hygienists performed professional person oral wellness care weekly [
]
- •
dental intendance provided by a dental surgeon, four–5 times a week [
[29]
- Bellissimo-Rodrigues W.T.
- Menegueti Chiliad.G.
- Gaspar G.Grand.
- Nicolini Due east.A.
- Auxiliadora-Martins M.
- Basile-Filho A.
- et al.
Effectiveness of a dental care intervention in the prevention of lower respiratory tract nosocomial infections amid intensive intendance patients: a randomized clinical trial.
- Crossref
- PubMed
- Scopus (27)
- Google Scholar
] Patients receiving dental care were compared to those receiving routine oral care.
- •
annual visit to the dentist, tooth, tongue and mucosa brushing three times a day and later on each repast [
] In add-on, those receiving the intervention received used an chlorhexidine mouth launder.
- •
almanac visit to the dentist, molar, tongue and mucosa brushing three times a day and after each meal [
]
Ii of the four studies identified a reduction in NV-HAP associated with the intervention (Table 3) [
,
]. 1 study recorded no cases of NV-HAP during the intervention phase [
[29]
- Bellissimo-Rodrigues West.T.
- Menegueti M.Yard.
- Gaspar M.Grand.
- Nicolini E.A.
- Auxiliadora-Martins Thou.
- Basile-Filho A.
- et al.
Effectiveness of a dental intendance intervention in the prevention of lower respiratory tract nosocomial infections amid intensive care patients: a randomized clinical trial.
- Crossref
- PubMed
- Scopus (27)
- Google Scholar
], while the quaternary and largest report did not identify a reduction in NV-HAP [
].
Dysphagia and NV-HAP prevention
Two not-randomised studies used dysphagia screening as the primary method for NV-HAP prevention [
35
- Schrock J.W.
- Lou L.
- Ball B.A.W.
- Van Etten J.
The use of an emergency department dysphagia screen is associated with decreased pneumonia in astute strokes.
- Google Scholar
,
36
- Titsworth W.L.
- Abram J.
- Fullerton A.
- Hester J.
- Guin P.
- Waters G.F.
- et al.
Prospective quality initiative to maximize dysphagia screening reduces infirmary-acquired pneumonia prevalence in patients with stroke.
- Crossref
- PubMed
- Scopus (72)
- Google Scholar
]. Schrock and colleagues used a pre-postal service quasi-experimental written report to evaluate rates of NV-HAP in patients with ischemic and haemorrhagic stroke both before and after the use of a dysphagia screen [
[35]
- Schrock J.Westward.
- Lou L.
- Ball B.A.Westward.
- Van Etten J.
The use of an emergency department dysphagia screen is associated with decreased pneumonia in acute strokes.
- Google Scholar
]. In the post report phase, a dysphagia screening examination was applied to all acute stroke patients in the emergency section. For patients In the haemorrhagic group, the incidence of NV-HAP decreased from xix% to 15% (P < 0.001), while in the ischemic stroke groups, NV-HAP rates decreased from 13.viii% to eight% (P = 0.007) [
[35]
- Schrock J.Westward.
- Lou 50.
- Ball B.A.W.
- Van Etten J.
The use of an emergency department dysphagia screen is associated with decreased pneumonia in astute strokes.
- Google Scholar
]. Titsworth et al. also examined an intervention in patients with ischemic or haemorrhagic stroke [
[36]
- Titsworth Westward.Fifty.
- Abram J.
- Fullerton A.
- Hester J.
- Guin P.
- Waters M.F.
- et al.
Prospective quality initiative to maximize dysphagia screening reduces infirmary-acquired pneumonia prevalence in patients with stroke.
- Crossref
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]. The intervention was a nurse-led bedside dysphagia screen and a rapid clinical swallow undertaken by a speech pathologist. The authors advise that this quality improvement initiative coincided with a reduction in NV-HAP from 6.5% to ii.8% among the stroke patients (P < 0.001) [
[36]
- Titsworth W.L.
- Abram J.
- Fullerton A.
- Hester J.
- Guin P.
- Waters M.F.
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Prospective quality initiative to maximize dysphagia screening reduces hospital-acquired pneumonia prevalence in patients with stroke.
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].
Mobility and NV-HAP prevention
We identified three studies that involved a form of physical activity equally a fashion of reducing the incidence of NV-HAP [
32
- Boden I.
- Skinner Eastward.H.
- Browning Fifty.
- Reeve J.
- Anderson L.
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,
]. Cuesy et al. conducted a randomised controlled trial examining the effect of turning and passive mobilisation on patients with acute ischemic stroke [
]. The turn-mob program, instigated during the intervention phase, included modifying the patient from supine position to right and left lateral recumbent position every ii h, in addition to passive mobilizations of the four limbs through each segment'due south entire range of motility, every half dozen h. Family members were also involved in this process. The intervention was associated with a decrease in NV-HAP (relative take chances of 0.39; 95% CI 0.19–0.79; P = 0.008) [
]. A randomised controlled trial undertaken by Boden et al. also reported a reduction in NV-HAP [
[32]
- Boden I.
- Skinner E.H.
- Browning 50.
- Reeve J.
- Anderson 50.
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- Crossref
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]. The intervention included pre-operative patient didactics, early ambulation and cocky-directed breathing exercises, and additional pre-operative physiotherapy. Although the primary upshot was mail-operative pulmonary complications, a reduction in NV-HAP was besides identified (Hr 0.45; 95% CI 0.26–0.78, P = 0.005) [
[32]
- Boden I.
- Skinner E.H.
- Browning L.
- Reeve J.
- Anderson L.
- Hill C.
- et al.
Preoperative physiotherapy for the prevention of respiratory complications later on upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial.
- Crossref
- PubMed
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]. Stolbrink et al. likewise undertook a physiotherapy-based intervention that involved early on mobilisation in patients following a hip fracture [
]. In this quasi-experimental study, the intervention was associated with a lower incidence of NV-HAP (HR 0.39; 95% CI 0.22–0.68; P = 0.001) [
].
Differences in NV-HAP definitions used in included manufactures
The manufactures included in this review used different definitions for determining cases of NV-HAP. These included chest radiography with clinical symptoms of pneumonia [
,
32
- Boden I.
- Skinner E.H.
- Browning L.
- Reeve J.
- Anderson L.
- Hill C.
- et al.
Preoperative physiotherapy for the prevention of respiratory complications later upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial.
- Crossref
- PubMed
- Scopus (107)
- Google Scholar
,
,
,
35
- Schrock J.W.
- Lou L.
- Ball B.A.West.
- Van Etten J.
The use of an emergency section dysphagia screen is associated with decreased pneumonia in acute strokes.
- Google Scholar
], Administrative coding data [
14
- Quinn B.
- Baker D.L.
- Cohen S.
- Stewart J.Fifty.
- Lima C.A.
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Bones nursing care to forbid nonventilator infirmary-acquired pneumonia.
- Google Scholar
,
38
- McNally Due east.
- Krisciunas G.P.
- Langmore S.E.
- Crimlisk J.T.
- Pisegna J.M.
- Massaro J.
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,
39
- Wagner C.
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Risk of stroke-associated pneumonia and oral hygiene.
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[20]
- Robertson T.
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- PubMed
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], Centers for Disease Control and Prevention (CDC) definition [
29
- Bellissimo-Rodrigues W.T.
- Menegueti M.G.
- Gaspar Thousand.Thou.
- Nicolini Due east.A.
- Auxiliadora-Martins Yard.
- Basile-Filho A.
- et al.
Effectiveness of a dental care intervention in the prevention of lower respiratory tract nosocomial infections among intensive intendance patients: a randomized clinical trial.
- Crossref
- PubMed
- Scopus (27)
- Google Scholar
,
36
- Titsworth W.L.
- Abram J.
- Fullerton A.
- Hester J.
- Guin P.
- Waters One thousand.F.
- et al.
Prospective quality initiative to maximize dysphagia screening reduces infirmary-acquired pneumonia prevalence in patients with stroke.
- Crossref
- PubMed
- Scopus (72)
- Google Scholar
], and national professional guidelines [
[20]
- Robertson T.
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Oral intensity: reducing non-ventilator-associated hospital-acquired pneumonia in care-dependent, neurologically impaired patients.
- PubMed
- Google Scholar
]. Some articles were less clear or did non specify the diagnostic approach [
,
].
Discussion
In this review, interventions from studies aimed at reducing NV-HAP, announced to be based broadly on the themes of improving oral care, increased mobility or motion and dysphagia management. The most mutual preventive strategy used to reduce NV-HAP was oral care. The studies included in our review focussed on improving oral care through educational activity, increasing frequency and or consistency of oral care provided and use of an antiseptic. Further, the highest quality studies evaluating the impact of improved oral intendance all utilised professionals in the field of dentistry, such as dentists and/or dental hygienists. However, while well-nigh of these studies were randomised controlled trials, they were largely conducted in residential aged care facilities, with only one randomised controlled study conducted in a hospital setting. The feasibility of implementing an intervention requiring dentistry input in a hospital setting is limited at best. There are challenges in improving the provision of oral care in the hospital setting. A contempo study illustrated this with an boilerplate of 1.half dozen tooth brushings per day, when the goal of the intervention was three per twenty-four hour period by the nursing staff [
[38]
- McNally E.
- Krisciunas M.P.
- Langmore South.Eastward.
- Crimlisk J.T.
- Pisegna J.Thou.
- Massaro J.
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- Google Scholar
]. A contempo review also identified variation in the reported frequency of oral intendance provided by nurses (range 2–three.v times a day) and the documented frequency of oral care in nursing notes (range 1.2–3.five times a mean solar day) for non-ventilated patients [
[41]
- Emery K.P.
- Guido-Sanz F.
Oral care practices in not-mechanically ventilated intensive intendance unit of measurement patients: an integrative review.
- Google Scholar
]. Farther, the lack of nurse-led randomised studies for NV-HAP prevention identified in this review highlights a critical issue for patient intendance. As nurses are primarily responsible for the daily intendance needs of patients, they take a vital office to play in the prevention of HAIs, including NV-HAP [
[42]
- Collins A.Southward.
Preventing health care–associated infections.
- Google Scholar
]. Three studies, Quinn et al. [
[fourteen]
- Quinn B.
- Bakery D.L.
- Cohen S.
- Stewart J.50.
- Lima C.A.
- Parise C.
Basic nursing intendance to preclude nonventilator infirmary-caused pneumonia.
- Google Scholar
], McNally et al. [
[38]
- McNally East.
- Krisciunas Grand.P.
- Langmore Due south.Due east.
- Crimlisk J.T.
- Pisegna J.M.
- Massaro J.
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- Google Scholar
] and Robertson et al. [
[twenty]
- Robertson T.
- Carter D.
Oral intensity: reducing non-ventilator-associated infirmary-acquired pneumonia in care-dependent, neurologically dumb patients.
- PubMed
- Google Scholar
], all emphasised the importance of nurse-led initiatives along with interdisciplinary collaboration as being vital to successful oral care interventions. Improvements in oral care are considered a modifiable chance factor for NV-HAP [
14
- Quinn B.
- Baker D.L.
- Cohen Southward.
- Stewart J.L.
- Lima C.A.
- Parise C.
Basic nursing care to prevent nonventilator hospital-acquired pneumonia.
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,
43
- Tablan O.C.
- Anderson Fifty.J.
- Besser R.
- Bridges C.
- Hajjeh R.
Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the healthcare infection control practices informational committee.
- Google Scholar
].
The differing antiseptic agents used every bit part of oral care interventions in the studies included in this review also warrant give-and-take, as uncertainty remains regarding the most appropriate clarified for oral care in the prevention of NV-HAP. Antiseptic agents such as chlorhexidine gluconate, sodium bicarbonate, hydrogen peroxide and cetylpyridinium chloride are examples of antiseptics that were used in the included studies. Povidone-iodine is also an antiseptic agent known to be used for oral care in the prevention of HAP in full general [
]. Findings from our review exercise not add to the existing show base of operations regarding the use of chlorhexidine gluconate in oral care for the prevention of pneumonia in the literature [
43
- Tablan O.C.
- Anderson Fifty.J.
- Besser R.
- Bridges C.
- Hajjeh R.
Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the healthcare infection control practices advisory committee.
- Google Scholar
,
,
46
- Torres A.
- Niederman Grand.S.
- Chastre J.
- Ewig S.
- Fernandez‐Vandellos P.
- Hanberger H.
- et al.
International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the direction of hospital-caused pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Guild (ERS), European Order of Intensive Intendance Medicine (ESICM), European Gild of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT).
- Google Scholar
,
47
- Kalil A.C.
- Metersky M.L.
- Klompas Thou.
- Muscedere J.
- Sweeney D.A.
- Palmer L.B.
- et al.
Direction of adults with hospital-caused and ventilator-associated pneumonia: 2016 clinical practice guidelines past the Infectious Diseases Order of America and the American Thoracic Society.
- Crossref
- PubMed
- Scopus (1367)
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]. Farther research on the effectiveness of chlorhexidine and other antiseptics for oral care in HAP prevention has been called for, including cost effectiveness analyses [
43
- Tablan O.C.
- Anderson L.J.
- Besser R.
- Bridges C.
- Hajjeh R.
Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the healthcare infection command practices advisory commission.
- Google Scholar
,
46
- Torres A.
- Niederman M.S.
- Chastre J.
- Ewig S.
- Fernandez‐Vandellos P.
- Hanberger H.
- et al.
International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the management of hospital-caused pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Order of Intensive Care Medicine (ESICM), European Gild of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT).
- Google Scholar
].
Our review also identified dysphagia screening and physical activity or movement, as constructive strategies for preventing NV-HAP. This supports findings from a narrative review of the literature by Pássaro et al. [
], which also showed a reduction in NV-HAP following the use of early mobilization interventions as well every bit prompt diagnosis and handling of dysphagia. However, given the lack of studies assessing these strategies in patients with NV-HAP (2 studies for dysphagia and three for physical activity) and the lack of randomised control designs, their effectiveness is uncertain, thus suggesting the need for further evaluation of these strategies.
The diversity of interventions used for NV-HAP prevention and settings makes comparisons, generalisability and translation into practise difficult. In addition, the small sample size of published studies [
twenty
- Robertson T.
- Carter D.
Oral intensity: reducing non-ventilator-associated hospital-caused pneumonia in care-dependent, neurologically dumb patients.
- PubMed
- Google Scholar
,
] poses a limitation to the generalisability of the findings. Hence, the challenges in designing future NV-HAP intervention studies include diagnoses, adequate sample sizes and ethical considerations around accessing a high-risk population. Every bit noted in our review, the methods used to diagnose NV-HAP varied and included definitions from the CDC guidelines [
[14]
- Quinn B.
- Bakery D.50.
- Cohen S.
- Stewart J.L.
- Lima C.A.
- Parise C.
Basic nursing care to prevent nonventilator infirmary-acquired pneumonia.
- Google Scholar
], Association of Medical Microbiology and Infectious Diseases Canada guidelines [
[xx]
- Robertson T.
- Carter D.
Oral intensity: reducing not-ventilator-associated infirmary-acquired pneumonia in intendance-dependent, neurologically dumb patients.
- PubMed
- Google Scholar
], clinical symptoms and signs, and radiological features [
]. While it is recognised that there is no gold standard for the diagnosis of NV-HAP or VAP [
[47]
- Kalil A.C.
- Metersky M.L.
- Klompas M.
- Muscedere J.
- Sweeney D.A.
- Palmer L.B.
- et al.
Management of adults with infirmary-acquired and ventilator-associated pneumonia: 2016 clinical do guidelines by the Infectious Diseases Gild of America and the American Thoracic Club.
- Crossref
- PubMed
- Scopus (1367)
- Google Scholar
], we propose that future studies should use NV-HAP definitions from point prevalence studies, such as the European Eye for Disease Prevention and Command [
[48]
European Centre for Illness Prevention and Control
Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute intendance hospitals – protocol version 5.3.
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]. The apply of standard definitions allows infection control and prevention professionals and infirmary epidemiologists to brand sensible comparisons among data from hospitals or against national data [
[42]
- Collins A.South.
Preventing health intendance–associated infections.
- Google Scholar
]. The use of definitions that are already familiar from current employ may too ameliorate the reliability of their application in studies.
While HAP is one of the nearly prevalent HAIs among hospitalised patients, the incidence of NV-HAP in hospitalised patients is relatively low [
]. Hence, a big sample size providing sufficient statistical power will be required for any study seeking to make up one's mind the furnishings of NV-HAP interventions. This big sample size, coupled with both the demand to undertake prospective diagnoses and difficulties in implementing oral care interventions, presents a major challenge. The incidence of NV-HAP is higher in high-take chances groups, such as the elderly or those with multiple co-morbidities; therefore, studying this blazon of grouping may aid a reduction in sample size. Still, the claiming with studying this type of group pertains to informed consent and the associated choice bias. Therefore, a stepped wedge design may be a useful study blueprint for hereafter NV-HAP studies [
[49]
- Prost A.
- Binik A.
- Abubakar I.
- Roy A.
- De Allegri Chiliad.
- Mouchoux C.
- et al.
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- Google Scholar
].
Our review has several limitations. The variability in the definitions of NV-HAP and the substantial clinical and methodological heterogeneity betwixt the included studies made it impossible to undertake a meta-analysis. The quality and risk of bias of one-tertiary of the studies included in the review had ratings of five or less, and therefore were considered to have a high hazard of bias and the potential to impact the report findings. In view of the findings from this newspaper, it appears that improving the quality and frequency of oral intendance, in addition to mobilisation may be useful interventions in reducing the incidence of NV-HAP. Nurse led randomised studies, to assess the effectiveness of an intervention or interventions to reduce the incidence of NV-HAP are required. Such studies need to be rigorously conducted and sufficiently powered.
Authorship statement
BM, PR, AC and AS conceived this written report. Hr, SC, SR contributed to data collection. All authors reviewed the manuscript and provided critical input. All authors approved the final version of this paper. BM was the lead for this projection.
Conflict of interest
Three of the authors have an editorial affiliation with the journal. They played no part whatsoever in the peer review procedure or decisions relating to this manuscript.
Funding
This study did not receive a grant or external funding to support its comport.
Provenance and peer review
Non deputed; externally peer reviewed.
Ethics
Non required, this is a systematic review of the literature.
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Article Info
Publication History
Published online: July 04, 2019
Accepted: June 13, 2019
Received in revised course: June 12, 2019
Received: March eight, 2019
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DOI: https://doi.org/10.1016/j.idh.2019.06.002
Copyright
© 2019 The Authors. Published by Elsevier B.Five. on behalf of Australasian College for Infection Prevention and Command.
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Source: https://www.idhjournal.com.au/article/S2468-0451%2819%2930021-5/fulltext
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