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American Journal of Critical Care. 2009;18: 319-328 doi:10.4037/ajcc2009121
Copyright © 2009 by the American Association of Critical-Care Nurses.
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CE Article

Oral Care Interventions and Oropharyngeal Colonization in Children Receiving Mechanical Ventilation

By Mavilde L.G. Pedreira, RN, PhD, Denise M. Kusahara, RN, MNSc, Werther Brunow de Carvalho, MD, PhD, Silvia Cristina Núñez, DDS, PhD and Maria Angélica S. Peterlini, RN, PhD. Mavilde L.G. Pedreira and Maria Angélica S. Peterlini are adjunct professors and Denise M. Kusahara is a pediatric critical care nurse, Nursing School, and Werther Brunow de Carvalho is an adjunct professor, Pediatrics Department, of the Federal University of São Paulo, Brazil. Silvia Cristina Núñez is a professor, Research Center for Dentistry Training and Advancement, São Paulo, Brazil.

Corresponding author: Mavilde Luz Gonçalves Pedreira, Nursing School, Federal University of São Paulo, Rua Napoleão de Barros, 754 office 113, Vila Clementino-São Paulo-Capital, Brazil CEP 04024002 (e-mail: mpedreira{at}unifesp.br).


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 Study Limitations
 Conclusion
 References
 
Background Recent progress in identification of oral microorganisms has shown that the oropharynx can be a site of origin for dissemination of pathogenic organisms to distant body sites, such as the lungs.

Objective To compare the oropharyngeal microbiological profile, duration of mechanical ventilation, and length of stay in the intensive care unit of children receiving mechanical ventilation who had pharmacological or nonpharmacological oral care.

Methods A randomized and controlled study was performed in a pediatric intensive unit in São Paulo, Brazil. A total of 56 children were randomly assigned to an experimental group (n=27, 48%) that received oral care with use of 0.12% chlorhexidine digluconate or a control group (n=29, 52%) that received oral care without an antiseptic. Oropharyngeal secretions were collected and cultured on days 0, 2, and 4, and at discharge.

Results The 2 groups had similar demographic characteristics, preexisting underlying diseases, and pharmacological, nutritional, and ventilatory support. Gram-negative bacteria were the predominant pathogens: Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enter-obacter species. The 2 groups did not differ significantly in the colonization of normal (P= .72) or pathogenic (P= .62) flora, in the duration of mechanical ventilation (P= .67), or in length of stay in the intensive care (P= .22).

Conclusion Use of chlorhexidine combined with nonpharmacological oral care did not decrease the colonization profile, duration of mechanical ventilation, or length of stay in critically ill children receiving mechanical ventilation.

Notice to CE enrollees:A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
  1. Describe the incidence of ventilator-associated pneumonia in the pediatric intensive care unit (PICU) patient population.
  2. Identify microorganisms that commonly colonize the oropharynx of PICU patients.
  3. Recognize the impact of an oral care routine using chlorhexidine on a PICU study group.
To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue." No CE test fee for AACN members.

Ventilator-associated pneumonia (VAP) is among the most frequently occurring nosocomial infections in critical care patients.1–5 A rate of 11.6 VAP episodes per 1000 days of mechanical ventilation in a pediatric intensive care unit (PICU) in the United States has been reported.6 In studies in Mexico7 and Brazil,8 rates were 28 and 18.7 episodes, respectively, per 1000 days of mechanical ventilation. Results from the US National Nosocomial Infections Surveillance System indicate that pneumonia accounts for approximately 15% of all hospital-associated infections, ranging from 4.7 cases in PICUs to 34.4 cases in burn ICUs.9 VAP accounts for 18% of the nosocomial infections in infants less than 2 months old, 20% of those in children between 2 months and 5 years old, 26% in children between 5 and 12 years old, and 21% in children more than 12 years old.6

Patients receiving mechanical ventilation have decreased salivary secretion, and oral cavity hygiene worsens, resulting in bacteria overgrowth.10 Oropharyngeal colonization with potentially pathogenic microorganisms is crucial in the pathogenesis of VAP. Oral care regimens that improve oral health status and modulate bacterial overgrowth could reduce the development of nosocomial VAP.1–4,11–15

Grap et al16 investigated the relationship between VAP and oral health status in a sample of 34 adults receiving mechanical ventilation. Alterations in oral health status occurred during the first 7 days after intubation, with microbial colonization of the oropharynx and trachea. Dental plaque and oral organisms increased over time; potential pathogens were identified in cultures of oral samples before or at the same time as the appearance of these organisms in tracheal aspirates, and higher dental plaque scores correlated with an increased risk for VAP.


Pneumonias account for 15% of all hospital-associated infections.

 

The Centers for Disease Control and Prevention guidelines9 for preventing health care–associated pneumonia recommend the development and implementation of a comprehensive oral hygiene program for patients in acute care settings who are at high risk for this type of pneumonia. Essentially 2 techniques are described to remove dental plaque and associated microbes in critically ill patients: mechanical intervention and direct pharmacological intervention with antimicrobial agents.17 Although mechanical removal may be an effective method for eliminating oral pathogens, and oral hygiene is considered standard nursing care, oral care is often neglected in critically ill patients or is performed by quickly swabbing the patient’s mouth.18

In a study19 to determine the frequency of oral care performed by nurses, the majority of nurses reported that they provided oral care 5 or more times per day for any patient who was intubated, but oral care was documented only a mean of 1.2 times per patient. Toothbrushing was used significantly more often in nonintubated patients than in intubated patients (P < .001), whereas sponge toothette swabs were used significantly more often in intubated patients than in nonintubated patients (P < .001). Similarly, Hanneman and Gusick20 highlighted that the use of mouthwash, toothbrush, and toothpaste, as well as the frequency of oral care interventions, was lower in intubated patients than in nonintubated patients.

DeRiso et al21 showed that inexpensive and easily done oropharyngeal decontamination with a 0.12% chlorhexidine oral rinse significantly reduced the nosocomial respiratory infection rate and mortality in a comparatively homogeneous population of adults undergoing heart surgery.

Unfortunately, little is known about the effects of oral care interventions in critically ill children. Evidence-based protocols for oral care for these children are not available, and oral hygiene measures are generally directed toward a patient’s comfort rather than removal of microbes. Thus, the purpose of our study was to analyze the oropharyngeal microbiological colonization profile of children receiving mechanical ventilation. We used 2 methods of oral decontamination: mechanical intervention alone and mechanical intervention plus 0.12% chlorhexidine. We also evaluated the effect of these interventions on the duration of mechanical ventilation and length of PICU stay.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 Study Limitations
 Conclusion
 References
 
Setting and Sample
This prospective, randomized, controlled study was performed in a PICU in São Paulo, Brazil. The aims, methods, benefits, discomforts, and potential risks of the interventions were described to each child’s parent or responsible adult according to the recommendations of the Helsinki Declaration. Of the 146 children admitted to the PICU during the 9 months of the study, 56 (38%) were selected for participation. Children were not eligible if they were newborns, fulfilled the Centers for Disease Control and Prevention criteria for pneumonia in infants and children at the time of PICU admission, were in the PICU for less than 48 hours, had a tracheotomy, or if informed consent had not been granted. A total of 47 intubated children and 9 nonintubated children (ie, those who received mechanical ventilation for <24 hours) were enrolled in the study.

The children were assigned randomly to 2 groups. For the experimental group, oral care included use of an oral gel containing chlorhexidine digluconate 0.12% as an active ingredient (chlorhexidine digluconate 0.12%; methylcellulose gel 2.12%, 25 g; gooseberry syrup, 4 drops; menthol solution 50%, 3 drops; and distilled water, to 30 g). The control group received the same oral care with the use of a similarly formulated gel without the antiseptic agent. The gel type was color coded and the nurses had no knowledge of the type of gel (with or without antiseptic) until the end of the study. Only the pharmacist was aware of the gel type used for each patient.

Procedures
Before the study, all PICU nurses were trained in oral care by a dentist who used a protocol designed to remove microorganisms from all mouth surfaces, including hard and soft tissues. The training included evaluation of a child’s oral status, selection of oral care equipment according to the child’s age, and a description of the desired outcome, preserving the integrity of oral and labial mucosa.

For each child, before oral care began, the child was placed in a lateral position to prevent pulmonary aspiration of secretions. The gel was applied on a toothbrush and the teeth were cleaned in quadrants; all teeth surfaces were cleaned (vestibular, lingual, occlusal, and incisal). After each quadrant was cleaned, 10 mL of water (dispensed via a syringe) was used to rinse the quadrant and continual aspiration was used to remove all the gel and debris. After all the teeth were cleaned, the ventral surface of the tongue was brushed with posterior-to-anterior movements. A sponge swab was then immersed in the gel and the gel was applied over all the oral mucosa. During the hygiene process and rinsing of each mouth quadrant, fluids and secretions were aspirated by using a vacuum aspirator. The protocol was used twice a day and took about 10 minutes to complete, depending on the child’s acceptance and clinical conditions. Nurses’ compliance with the oral care protocol during the study period was evaluated by 2 trained researchers in a random fashion, and retraining was conducted when necessary.


Little is known about the effects of oral care interventions in critically ill children.

 

Measures
The dependent variables selected for the study were the profile of oropharyngeal colonization, duration of mechanical ventilation, and length of PICU stay. Oropharyngeal colonization was analyzed by using a qualitative microbiological culture assay of samples from the tonsillar area and the upper posterior part of the oropharynx. Samples were collected during the first 24 hours of PICU admission (day 0), at 48 hours (day 2), at 96 hours (day 4), and at the time of discharge from the PICU.

All the secretions were collected by 3 trained nurses 8 to 10 hours after oral care. A standard protocol was used for sample collection, storage, labeling, and transport to the laboratory. A sterile swab plastic stick 15 cm long with a cotton tip was pressed and rolled on the tonsillar area and the upper posterior part of the oropharynx to obtain oropharyngeal secretions. The swab with the sample secretions was immersed in a sterile tube containing 5 mL of Stuart agar. Then the tube was labeled and immediately transported to the laboratory.


On study admission, 41% of oral samples were colonized with pathogenic bacteria.

 

In the microbiological laboratory, the samples were cultured on blood agar, chocolate agar, eosin–methylene blue agar, and Sabouraud agar, and incubated according to controlled atmosphere, temperature, time, and humidity parameters for qualitative microbiological identification. After incubation, growth of colonies was evaluated by 2 microbiologists, and analyses of microbial resistance to antibiotics were done. The diffusion disk technique with Mueller-Hinton agar was used for qualitative analyses. Length of incubation, ionic concentration, temperature, nutritional characteristics of the plaque, incubation, and application of the antibiotics disks to be tested were done in accordance with the recommendations of the Clinical and Laboratory Standards Institute.22 Sensitivity and resistance were determined by comparing the size of the halos with the established standards.22

The following antibiotics were used in the sensitivity analyses, as determined by the pattern established in the hospital for the years 2005 and 2006: amikacin, tobramycin, gentamicin, cefepime, ceftazidime, ciprofloxacin, imipenem, meropenem, piperacillin, disodium clavulanate, polymyxin, ceftriaxone, and sulfamethoxazole plus trimethoprim.

Duration of mechanical ventilation (in hours) and length of PICU stay (in days) were determined. Other data collected included each patient’s age; sex; nutritional status according to a Z score (normal, malnutrition, overweight); clinical evaluation of the condition of the oral mucosa (presence or absence of alterations such as moniliasis, gingivitis, and injuries); oral health status according to the DMFT (decayed, missing due to caries, and filled teeth) index, previous hospital length of stay; presence of infectious or chronic disease at admission; use of antibiotics; type of admission (elective or emergency); diagnoses (clinical or surgical); Nine Equivalents of Nursing Manpower Use Score; use of drugs that could affect oropharyngeal colonization (central nervous system suppressors, salivary secretion modifiers, immunological suppressors, gastric pH modifiers); characteristics of intubation, including indication (emergency and elective), type (oral or nasal), and type of endotracheal tube (cuffed or uncuffed); presence of enteral tubes; and outcome (discharge or death). All patients were followed up until discharge from the PICU.

Categorical variables were evaluated by using {chi} 2 and Fisher exact tests. Numerical variables were evaluated by using a t test or analysis of variance. Rejection of the null hypothesis was set at {alpha} = .05.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 Study Limitations
 Conclusion
 References
 
Characteristics of the Sample
Overall, 56 children were enrolled: 29 (52%) in the control group and 27 (48%) in the experimental group. At baseline, both groups had similar demographic characteristics, preexisting medical conditions, underlying diseases, and pharmacological and nutritional support. The characteristics of intubation did not differ significantly between the groups. Most of the patients had infectious disease at the time of PICU admission. The 2 groups did not differ in the Nine Equivalents of Nursing Manpower Use Score, clinical conditions of the oral cavity according to the DMFT index, health status of the oral mucosa, mean duration of mechanical ventilation, or mean length of PICU stay (Table 1Go).


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  		Table 1 Baseline characteristics of the sample

 
Oropharyngeal Colonization
Because of discharge (control group, 85%; experimental group, 81%) and death (control group, 15%; experimental group, 19%), sequential samples of oropharyngeal samples were obtained from 56 patients on day 0, from 52 on day 2, from 31 on day 4, and from 9 at PICU discharge. The effects of the experimental intervention on colonization by pathogenic (Staphylococcus aureus, Klebsiella pneumoniae, Enterobacter species, Pseudomonas aeruginosa, Acinetobacter baumannii, Proteus mirabilis, Morganella morganii) and nonpathogenic (Streptococcus viridans, coagulase-negative staphylococci, Moraxella species) microorganisms are presented in the FigureGo.


Figure 1
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  		Figure Percentage of cultures positive for pathogenic and normal microorganisms in samples of oropharyngeal secretions from children treated with toothbrushing alone (control group) or with toothbrushing plus 0.12% chlorhexidine (experimental group).
Abbreviation: PICU, pediatric intensive care unit.

 
On admission, overall 84% (control group, 86%; experimental group, 85%) of oropharyngeal samples contained normal flora, and 41% (control group, 38%; experimental group, 44%) contained pathogenic flora. The frequency of oropharyngeal colonization by normal flora (P = .72) and pathogenic flora (P = .62) did not differ significantly between the 2 groups.

During the first 48 hours of PICU admission, the number of children colonized with pathogenic microorganisms decreased in the experimental group and increased in the control group. Table 2Go gives the number of children colonized and the microorganisms identified.


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  		Table 2 Microbiological profile of cultures of oropharyngeal secretions from critically ill children in a pediatric intensive care unit (PICU), by group studieda

 
Streptoccocus viridans was detected in most of the samples in both groups. Coagulase-negative staphylococci and Moraxella species were detected more often in the experimental group than in the control group. Overall, gram-negative bacteria were the predominant species. The frequency of A baumannii and P aeruginosa was higher in the control group than in the experimental group, and that of K pneumoniae and Enterobacter species was higher in the experimental group (Table 2Go).

A total of 26 samples contained pathogenic bacteria, and 24 (92%) of the 26 were antibiotic resistant, such as K pneumoniae strains resistant to β-lactamase, methicillin-resistant S aureus, carbapenem-resistant P aeruginosa and A baumannii, and cephalosporin-resistant Enterobacter species (Table 3Go).


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  		Table 3 Pathogenic microorganisms’ resistance according to groupa

 
The effects of chlorhexidine on oropharyngeal colonization are shown in the FigureGo and Table 4Go. Colonization by pathogenic bacteria did not differ between the 2 groups of children. From day 0 to day 2, the number of children with an increase in the number of samples positive for pathogenic flora was greater in the control group than in the experimental group, but the difference was not significant. Similarly, the colonization of the oral cavity by normal flora did not differ between the 2 groups of children (FigureGo and Table 4Go).


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  		Table 4 Changes in colonization by normal and pathogenic floraa

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
Study Limitations
 Conclusion
 References
 
The oral cavity can be a site of origin for dissemination of pathogenic organisms to distant body sites, such as the lungs.23 The Centers for Disease Control and Prevention have suggested that nosocomial respiratory infections are due to 4 methods of inoculation: aspiration of oropharyngeal organisms, inhalation of aerosols containing bacteria, hematogenous spread from distant body sites, and bacterial translocation from the gastrointestinal tract.9 Of these 4, aspiration is thought to be the most important. Thus, a reduction in the oropharyngeal microbial flora would theoretically have a marked effect on oral colonization and the occurrence of respiratory nosocomial infections.21


Pathogenic colonization decreased in the chlorhexidine group and increased in the control group.

 

We found no difference between the control and experimental groups in colonization by pathogenic bacteria. Fewer children in the experimental group had an increase from day 0 to day 2 in the number of samples positive for growth of pathogenic microorganisms, but the difference was not significant. Similarly, colonization of the oral cavity by normal flora did not differ between the 2 groups.

In a systematic review and meta-analysis of the effect of oral decontamination, with antiseptics or antibiotics, on the incidence of VAP and mortality in adults receiving mechanical ventilation, Chan et al24 found that oral decontamination with antiseptics was associated with a lower risk for VAP. However, neither antiseptic nor antibiotic oral decontamination reduced mortality, duration of mechanical ventilation, or length of ICU stay.

Oropharyngeal Colonization
We found a high rate of oropharyngeal colonization in PICU patients. During the first 24 hours of PICU admission, the oropharynx was colonized by aerobic pathogens in 40% of the children. In addition, some of these children had colonization by multidrug-resistant pathogens. Four days after admission, more than 50% had colonization by bacterial pathogens. We found no significant differences between the 2 groups in colonization characteristics. These results were similar to those of Fourrier et al25 in a study of critically ill adults receiving mechanical ventilation. Approximately 50% of the patients had cultures positive for bacterial pathogens at admission, and 33% of these patients had aerobic pathogens, mainly gram-negative bacteria.25

In our study, the aerobic gram-negative bacteria identified most frequently were P aeruginosa, Escherichia coli, K pneumoniae, and various species of Acinetobacter. The number of infections caused by gram-positive bacteria is increasing rapidly in adult ICUs, particularly infections caused by methicillin-resistant strains of S aureus. The incidence of VAP related to multidrug-resistant pathogens has also increased, because of indiscriminate use of antibiotics, prolonged hospitalization, high frequency of antibiotic resistance in the community, and immunosuppression.2,3

Children in the experimental group had more species of Enterobacteriaceae, such as Enterobacter species (75%), E coli (100%), and K pneumoniae (71%), than did children in the control group. Similar findings were obtained in another study1 in which treatment with chlorhexidine caused a greater reduction in gram-positive bacteria than in gram-negative organisms.

Dental plaque is due to bacterial colonization of the surfaces of teeth, soft tissues, and dental prostheses via selective adherence mechanisms. Dental plaque is a biofilm, a dynamic and complex system that contains microorganisms embedded in an extracellular matrix. Plaque mass increases by cumulative addition of aerobic, anaerobic, and filamentous microorganisms. Numerous factors are involved in the development of plaque; however, poor oral hygiene and lack of mechanical elimination of microorganisms are the main factors leading to proliferation and accumulation of dental plaque and subsequent colonization.26

Adherent streptococci drench the salivary pellicle on binding sites during the first 2 to 8 hours of plaque deposition. This growth period is independent of personal characteristics, surface, and time and appears to depend on cell density. Initial colonization of enamel surfaces by bacteria occurs in 3 stages: saturation of pellicular binding sites, accumulation of organisms via a variety of mechanisms until a critical density is reached, and density-dependent growth.27

Several studies1,25,26 have suggested that oropharyngeal colonization plays an important role as a reservoir of nosocomial colonization and support the hypothesis that antiseptic decontamination of dental plaque might decrease the rate of acquired nosocomial infection in ICU adult patients. However, few data support this hypothesis for infants and children, and we found that in children in a PICU, the effects of oral care consisting of mechanical intervention plus chlorhexidine did not differ from the effects of oral care consisting of mechanical intervention alone.

Chlorhexidine
Chlorhexidine increases the permeability of bacterial cell walls in a dose-dependent manner by interacting with anionic receptors on the bacterial surface.15 Caton et al28 found that rinsing with chlorhexidine solution before mechanical cleaning had a profound and sustained effect on the aerobic and facultative flora of the oral cavity and may contribute to a variety of clinical benefits. A meta-analysis29 of the efficacy of topical chlorhexidine for prevention of VAP indicated that topical chlorhexidine is beneficial in preventing VAP and that the benefit is most marked in cardiac surgery patients.


A total of 92.3% of the pathogenic bacteria were antibiotic-resistant strains.

 

To document the effect of antiseptic decontamination of gingival and dental plaque on the rate of nosocomial bacteremias and respiratory infections acquired in the ICU, Fourrier et al26 carried out a prospective, multicenter, double-blind, placebo-controlled efficacy study. A total of 228 edentulous adults requiring endotracheal intubation and mechanical ventilation had 0.2% chlorhexidine gel or a placebo gel applied to gingival and alveolar processes 3 times a day. Compared with the control group, patients treated with chlorhexidine had fewer dental plaque cultures that remained negative for bacterial growth or became negative after 5 days, but the difference was not statistically significant. In our study, chlorhexidine influenced the growth of both normal flora and pathogenic flora, decreasing the number of microorganisms in cultures of oropharyngeal secretions mainly after 2 days of oral care, but the results were not significant.


No difference was found in colonization between groups by pathogenic bacteria species.

 

The number of chlorhexidine applications in our study (2/d) differed from the number in the study of Fourrier et al26 (3/d). Although this variation may be important, other investigators30 found no direct relationship between time interval and the development of biofilms. The characteristics of the microflora in children may be relevant for the chlorhexidine effect. Sharma et al31 concluded that in children 13 to 14 years old, a once-a-day unsupervised toothbrushing had the same effect on plaque formation as did a twice-daily mouth rinsing with 0.2% chlorhexidine. In our study, all treatments were performed twice a day in all children for several reasons, including better compliance with the protocol, lack of definitive evidence to determine the most appropriate method of oral hygiene, and lack of knowledge about the effects of chlorhexidine in young children.32,33

Studies21,25,26,34 on the effects of oral chlorhexidine have yielded conflicting results. In a meta-analysis, Pineda et al34 did not find any clinical benefits of regular oral application of chlorhexidine on the incidence of nosocomial pneumonia and mortality rate in critically ill patients requiring mechanical ventilation. Fourrier et al25 investigated the effect of antiseptic decontamination of dental plaque on plaque colonization by aerobic pathogens and nosocomial infections in 60 adult patients receiving mechanical ventilation. In that study, antiseptic decontamination with a 0.2% chlorhexidine gel decreased dental bacterial colonization on day 5 to 7 after admission, but the effect did not persist after 10 days.

In an in vitro model,35 the effect of chlorhexidine was time dependent, and exposure times of 30 seconds had little effect on the number of viable bacteria recovered from oral biofilms. Even at 0.2%, chlorhexidine was ineffective against dental plaque after 5 minutes of exposure and required 60 minutes to achieve an effective killing. Therefore, one reason for the lack of effect of our experimental protocol may be insufficient contact time with bacteria; increased contact times might be effective.

Another key point is microbial resistance. Irizarry et al36 reported that antibiotic-resistant microorganisms had a reduced susceptibility to antiseptic and disinfectant agents such as chlorhexidine. Biocide resistance among microorganisms has been considered an important clinical issue.37 In a study by Suller and Russell38 reported in 1999, the minimal inhibitory concentration of chlorhexidine for methicillin-resistant S aureus was 1.5- to 3-fold greater than that for methicillin-sensitive S aureus.

In a recent study, Vali et al39 observed reduction in susceptibility of pathogens to chlorhexidine, and therefore reduced microbial susceptibility to biocides may be a serious concern in clinical practice.

Clinical studies24,28,29 involving critically ill patients have shown that inadequate salivary flow promotes the development of pharyngeal mucositis and increased colonization by aerobic pathogens. The presence of endotracheal or feeding tubes contributes to the formation of biofilms strongly resistant to antiseptics or antibiotics. Isolates from the initial samples in our study had high indices of antibiotic resistance; therefore, these isolates may have been less susceptible to the effects of chlorhexidine than antibiotic-sensitive isolates would be.

Toothbrushing
The lack of significant differences in our study may be related to the mechanical intervention of toothbrushing. Use of a toothbrush is widely considered to be the only effective means to remove dental plaque, but toothbrushing is not widespread in orally intubated children. To the best of our knowledge, no investigators have evaluated the effect of oral care with pharmacological and mechanical interventions in critically ill children. Thus, comparisons of our results with results from adult populations are difficult. Furthermore, a direct comparison between adults and children may be difficult because of the lack of knowledge of differences in oropharyngeal colonization in these 2 groups.


   Study Limitations
Top
 Abstract
 Methods
 Results
 Discussion
 Study Limitations
Conclusion
 References
 
This study was limited by a small sample for all 4 time points. Conversely, the results do provide unique, preliminary data on oral care in children receiving mechanical ventilation, suggesting that toothbrushing alone can be as effective as toothbrushing plus a pharmacological intervention to control overgrowth of oropharyngeal pathogens in PICU patients. Future research should address issues such as the effect of oral care on the development of VAP in children; depending on the results, the use of oral care protocols may be an important part of achieving evidence-based care in critically ill children.


   Conclusion
Top
 Abstract
 Methods
 Results
 Discussion
 Study Limitations
 Conclusion
References
 
The addition of a pharmacological intervention to oral care in critically ill children did not change the profile of microorganisms that colonized the oropharynx, duration of mechanical ventilation, or length of PICU stay.


   ACKNOWLEDGMENTS
 
This research was done at the Nursing School, Federal University of São Paulo.

FINANCIAL DISCLOSURES
This research was supported by grant 04-13361-2, Fun-dação de Amparo a Pesquisa do Estado de São Paulo.

eLetters
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   REFERENCES
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 Abstract
 Methods
 Results
 Discussion
 Study Limitations
 Conclusion
 References
 

  1. Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006; 173(12):1348–1355.[Abstract/Free Full Text]
  2. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.[Free Full Text]
  3. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002;165(7):867–903.[Abstract/Free Full Text]
  4. Cook DJ, Walter SD, Cook RJ, et al. Incidence and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med. 1998;129(6):433–440.[Abstract/Free Full Text]
  5. Prade SS, Oliveira ST, Rodrigues R, et al. Estudo brasileiro da magnitude das infecções hospitalares em hospitais terciários. Rev Contr Infect Hosp MS. 1995;2(2):11–24.
  6. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in pediatric intensive care units in the United States. National Nosocomial Infections Surveillance System. Pediatrics. 1999;103(4):e39.[Abstract/Free Full Text]
  7. Martinez-Aguilar G, Anaya-Arriaga M del C, Avilla-Figueroa C. Incidencia de bacteriemia y neumonía nosocomial en una unidad de pediatría [Incidence of nosocomial bacteremia and pneumonia in a pediatric unit]. Salud Publica Mex. 2001;43(6):515–523.[Medline]
  8. Abramczyk ML, Carvalho WB, Carvalho ES, Medeiros EA. Nosocomial infection in a pediatric intensive care unit in a developing country. Braz J Infect Dis. 2003;7(6):375–380.[Medline]
  9. Tablan OC, Anderson LJ, Besser R, et al; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1–36.[Medline]
  10. Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med. 2006; 32(2):230–236.[CrossRef][Medline]
  11. Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention. Respir Care. 2005;50(6): 725–739.[Medline]
  12. Robert R, Grollier G, Frat JP, et al. Colonization of lower respiratory tract with anaerobic bacteria in mechanically ventilated patients [published correction appears in Intensive Care Med. 2003;29(11):2107]. Intensive Care Med. 2003; 29(7):1062–1068.[CrossRef][Medline]
  13. Garrouste-Orgeas M, Chevret S, Arlet G, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients: a prospective study based on genomic DNA analysis. Am J Respir Crit Care Med. 1997; 156(5):1647–1655.[Abstract/Free Full Text]
  14. Crnich CJ, Safdar N, Maki DG. The role of intensive care unit environment in the pathogenesis and prevention of ventilator-associated pneumonia. Respir Care. 2005;50(6): 813–836.[Medline]
  15. Limeback H. Implications of oral infections on systemic diseases in the institutionalized elderly with a special focus on pneumonia. Ann Periodontol. 1997;3(1):262–275.
  16. Grap MJ, Munro CL, Elswick RK Jr, Sessler CN, Ward KR. Durations of action of a single, early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: a pilot study. Heart Lung. 2004;33(2):83–91.[CrossRef][Medline]
  17. Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care. 2004;13(1): 25–34.[Abstract/Free Full Text]
  18. Hixson S, Sole ML, King T. Nursing strategies to prevent ventilator-associated pneumonia. AACN Clin Issues. 1998; 9:76–90.[Medline]
  19. Grap MJ, Munro CL, Ashtiani B, Bryant S. Oral care interventions in critical care: frequency and documentation. Am J Crit Care. 2003;12(2):113–119.[Abstract/Free Full Text]
  20. Hanneman SK, Gusick GM. Frequency of oral care and positioning of patients in critical care: a replication study. Am J Crit Care. 2005;14(5):378–386.[Abstract/Free Full Text]
  21. DeRiso AJ II, Ladowiski JS, Dillon TA, Justice JW, Peterson AC. 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;109(6):1556–1561.[Abstract/Free Full Text]
  22. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: Fifteenth Informational Supplement. Wayne, PA: Clinical and Laboratory Standards Institute; 2005. Document M100–S15.
  23. Brennan MT, Bahrani-Mougeot F, Fox PC, et al. The role of oral microbial colonization in ventilator-associated pneumonia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;98(6):665–672.[CrossRef][Medline]
  24. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ. 2007;334:889.[Abstract/Free Full Text]
  25. Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M, Chopin C. Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med. 2000; 26(9):1239–1247.[CrossRef][Medline]
  26. Fourrier F, Dubois D, Pronnier P, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med. 2005;33(8):1728–1735.[CrossRef][Medline]
  27. Liljemark WF, Bloomquist CG, Reilly BE, et al. Growth dynamics in a natural biofilm and its impact on oral disease management. Adv Dent Res. 1997;11(1):14–23.[Abstract/Free Full Text]
  28. Caton JG, Blieden TM, Lowenguth RA, et al. Comparison between mechanical cleaning and an antimicrobial rinse for the treatment and prevention of interdental gingivitis. J Clin Periodontol. 1993;20(3):172–178.[CrossRef][Medline]
  29. Chlebicki MP, Safdar N. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med. 2007;35:595–602.[CrossRef][Medline]
  30. Al-Ahmad A, Wunder A, Auschill TM, et al. The in vivo dynamics of Streptococcus spp, Actinomyces naeslundii, Fusobacterium nucleatum and Veillonella spp in dental plaque biofilm as analysed by five-colour multiplex fluorescence in situ hybridization. J Med Microbiol. 2007;56(pt 5):681–687.[Abstract/Free Full Text]
  31. Sharma U, Jain RL, Pathak A. A clinical assessment of the effectiveness of mouthwashes in comparison to toothbrushing in children. J Indian Soc Pedod Prev Dent. 2004; 22(2):38–44.[Medline]
  32. Berry AM, Davidson PM. Beyond comfort: oral hygiene as a critical nursing activity in the intensive care unit. Intensive Crit Care Nurs. 2006;22(6):318–328.[CrossRef][Medline]
  33. Ross A, Crumpler J. The impact of an evidence-based practice education program on the role of oral care in the prevention of ventilator-associated pneumonia. Intensive Crit Care Nurs. 2007;23(3):132–136.[CrossRef][Medline]
  34. Pineda LA, Saliba RG, El Sohl AA. Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Crit Care. 2006;10:R35. http://www.ccforum.com/content/10/1/R35. Published February 20, 2006. Accessed April 8, 2009.[CrossRef][Medline]
  35. Hope CK, Wilson M. Analysis of the effects of chlorhexidine on oral biofilm vitality and structure based on viability profiling and an indicator of membrane integrity. Antimicrob Agents Chemother. 2004;48(5):1461–1468.[Abstract/Free Full Text]
  36. Irizarry L, Merlin T, Rupp J, Griffith J. Reduced susceptibility of methicillin-resistant Staphylococcus aureus to cetylpyridinium chloride and chlorhexidine. Chemotherapy. 1996;42(4): 248–252.[Medline]
  37. Fraise AP. Susceptibility of antibiotic-resistant cocci to biocides. J Appl Microbiol. 2002;92(suppl):158S–162S.
  38. Suller MTE, Russell AD. Antibiotic and biocide resistance in methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus. J Hosp Infect. 1999;43(4):281–291.[CrossRef][Medline]
  39. Vali L, Davies SE, Lai LL, Amyes SG. Frequency of biocide resistance genes, antibiotic resistance and the effect of chlorhexidine exposure on clinical methicillin-resistant Staphylococcus aureus isolates. J Antimicrob Chemother. 2008;61(3):524–532.[Abstract/Free Full Text]

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