Nosocomial Pneumonia—Oral Care as Part of a Ventilator Associated Pneumonia Prevention Effort

Nosocomial pneumonia presents a complex treatment challenge for healthcare professionals which increases risk of morbidity and mortality for patients in all healthcare settings, from acute to long term care. The impact of nosocomial pneumonia includes:

• increased length of stay
• increased patient care intensity for staff
• higher facility resource utilization levels
• substantially increased healthcare costs

Ventilated patients are particularly at risk for nosocomial pneumonia and Ventilator-Associated Pneumonia (VAP):

• Ventilated patients are at higher risk for pneumonia due to aspiration of oral secretions related to endotracheal intubation⁽¹⁾
• VAP can occur in greater than 10% of ventilated patients.^(2,3)
• Hospital Associated Pneumonia (HAP) potential increases with length of mechanical ventilation by 6-21 times⁽¹⁾

Recent studies have found that a number of patient care measures, including oral hygiene, can help reduce pneumonia rates. Oral hygiene has been determined to be important as:

• the oral cavity can be colonized with pathogens that can lead to nosocomial pneumonia and VAP.^{(2, 4, 5)}
• dental plaque can be a critical reservoir for these bacteria. ^(6,7)
• Studies have shown a 60% reduction in VAP rates after implementation of a comprehensive oral care program.⁽⁸⁾
• Patients in long-term care settings are at increased risk of Community Acquired Pneumonia (CAP) due to aspiration of oral secretions from dysphagia caused by stroke, Alzheimer’s disease, Parkinson’s disease and other conditions.^(9,10)

Formal oral care protocols have been shown to play an important role in reducing nosocomial pneumonia, including VAP, by reducing dental plaque and bacteria levels in the oral cavity through routine brushing and cleaning of the mouth. These findings led to the CDC Guidelines for Preventing Healthcare-Associated Pneumonia, 2003, which recommends that healthcare facilities “develop and implement a comprehensive oral-hygiene program” to reduce pneumonia rates.

References:

1. CDC. Guidelines for Preventing Healthcare Associated Pneumonia, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee, 2003.
2. Sole ML, et al. Bacterial Growth in Secretions and on Suctioning Equipment of Orally Intubated Patients. Am J Crit Care. 2002 Mar;11(2):141-9.
3. Ibrahim EH, Tracy L, et al. The Occurrence of Ventilator-Associated Pneumonia in a Community Hospital. Chest 2001; 120:555-561.
4. Binkley C, Furr LA, et al. Survey of Oral Care Practices in US Intensive Care Units. Am J Infect Control 2004: 32:161-169.
5. Munro CL, et al. Oral Health and Care in the Intensive Care Unit; State of the Science. Am J Crit Care. 2004 Jan;13(1):25-33.
6. Fourrier F, Duvivier B, et al. Colonization of Dental Plaque: A Source of Nosocomial Infection in ICU Patients. Crit Care Med 1998; 26:301-308.
7. El-Solh AA, Peitrantoni C, et al. Colonization of Dental Plaques: A Reservoir of Respiratory Pathogens for Hospital-Acquired Pneumonia in Institutionalized Elders. Chest 2004;126:1575-1582.
8. Schleder B, Stott, K. The Effect of a Comprehensive Oral Care Protocol on Patients at Risk for Ventilator-Associated Pneumonia. J Advocate Health Care. Spr/Sum 2002;4(1):27-30.
9. Coleman PR. Pneumonia in the Long Term Care Setting: Etiology, Management and Prevention. J Gerontol Nurs. 2004 Apr;30(4):14-23.
10. Marik PE, Kaplan D. Aspiration Pneumonia and Dysphagia in the Elderly. Chest 2003; 124:328-336.
11. Rello J, et al. Epidemiology and Outcomes of Ventilator Associated Pneumonia in a Large U.S. Database. Chest 2002 122: 2115-2121.