health goes south when pathogens and reflux linger in · pdf file9/19/2016 1 health goes south...

9/19/2016

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Health Goes South

When Pathogens

and Reflux Linger in the Mouth

Peggy Prinz Luebbert

MS,CIC,CHSP,CSPDT

[email protected]

Objectives

Describe how the mouths of critically il l patients undergo

radical changes to become reservoirs of pathogens

Identify the means by which poor oral care in the ICU can

result in complications including pneumonia

List recommended oral care interventions and the associated

evidence-based rationales

PNEUMONIA

CAP

HAP

COMMUNITY-

ACQUIRED

PNEUMONIA

HOSPITAL-

ACQUIRED

PNEUMONIA 3 million US cases

275,000 US cases

2004 National Hospital Discharge Survey

Carol J. DeFrances, Ph.D., and Michelle N. Podgornik, M.P.H., CDC Division of Health Care Statistics

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PNEUMONIA

CAPVAP

HAP

COMMUNITY-

ACQUIRED

PNEUMONIA

Ventilator-Associated

Pneumonia

HOSPITAL-

ACQUIRED

PNEUMONIA

The Cost of HAP & VAP in Lives and $$

Incidence: 3rd most common cause of infection in healthcare -

250,000/year1

2nd most common infection in ICU - 100,000/year1

One out of four ICU infections is HAP or VAP2

90% of ICU pneumonia is VAP2

6-20 fold higher risk of pneumonia in vented patients3

9%-27% of ventilated patients3

Higher VAP rate in Medical ICUs3

1Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports 20072ATS Guidelines for mgmt. of adults with HAP, VAP and HCAP. Am J Respir Crit Care Med 2005;171: 388-416. 3Safdar et al. Clinical and economic consequences of VAP: A systematic review. Crit Care Med 2005 33(10):2184-2193.

The Cost of HAP & VAP in Lives and $$

Mortality rate: Highest infection mortality – 36% of HAI deaths

Crude: 30-70% of HAP patients

Attributable: 33-50%

VAP 15%-50% higher than non-ventilated HAP patients

Increased costs: >$40,000 per incident

Additional mean ICU Length of Stay of 6 days

Additional Total Hospital LOS 7-9 days

1Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports 20072ATS Guidelines for mgmt. of adults with HAP, VAP and HCAP. Am J Respir Crit Care Med 2005;171: 388-416. 3Safdar et al. Clinical and economic consequences of VAP: A systematic review. Crit Care Med 2005 33(10):2184-2193.

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http://w ww.cdc.gov/nhsn/PDFs/training/2015/VAE-Training-

2015.pdf

Clinical Presentation of Pneumonia

•Purulent

secretions

•Densities on

Chest x-ray

•Fever

•Leukocytosis

(high wbc)

Early and Late VAP

Time Pathogens

Early

Onset VAP

Pneumonia that

develops between 48-96

hours after being placed

on the ventilator

Usually include:

Staphylococcus aureus

(Methicillin sensitive-MSSA)

Haemophilus influenza

Streptococcus pneumoniae

Late

Onset VAP

Pneumonia that

develops after 96 hours

(≥5 days) on ventilator

Usually include:

Staphylococcus aureus

(Methicillin resistant – MRSA)

Pseudomonas aeruginosa

Acinetobacter or

Enterobacter

Kollef MH. The Prevention of Ventilator-Associated Pneumonia. 1999. New England Jour Med. Vol. 340:8, 627-634.

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Why are Ventilated Patients

more susceptible to Pneumonia?

Why are Ventilated Patients

more susceptible to Pneumonia?

1. Air filtration in nasal cavity

2. Mucociliary escalator

3. Cough mechanism

Bypassed

Blocked

Inhibited

Normal Clearance Mechanisms and Reflexes are:

The Path to VAP

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The Path to VAP

The Path to VAP

The Path to VAP

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PNEUMONIA

CAPVAP

HAP

COMMUNITY-

ACQUIRED

PNEUMONIA

Ventilator-Associated

Pneumonia

HOSPITAL-

ACQUIRED

PNEUMONIA

ASPIRATION

PNEUMONIA

Aspiration pneumonia

30% of those who die of pneumonia are diagnosed with aspiration pneumonia.

Most common cause of death in patients with dysphagia due to neurologic disorders

5 to 15 percent of cases of community acquired pneumonia (CAP) are

aspiration pneumonia

Incidence of aspiration pneumonia is 18 percent in nursing home

acquired pneumonia (HCA)

Aspiration pneumonitis occurs in approximately 10 percent of patients

who are hospitalized after a drug overdose

Occurs in approximately 1 of 3000 operations in which general anesthesia is administered and accounting for 10 to 30 percent of all deaths

associated with anesthesia

Aspiration Definitions Aspiration: the inhalation of oropharyngeal or gastric contents into the

larynx and lower respiratory tract.

Aspiration pneumonitis (Mendelson’s syndrome): a chemical injury

caused by the inhalation of sterile gastric/bile contents. Also known as “chemical pneumonitis or “acid pneumonitis”

Aspiration pneumonia: an infectious process caused by the inhalation of oropharyngeal secretions that are colonized by pathogenic bacteria.

Both conditions can overlap in one patient

Other aspiration syndromes include airway obstruction, lung abscess, exogenous lipoid pneumonia, chronic interstitial fibrosis, and

Mycobacterium fortuitum pneumonia.

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Aspiration pneumonitis

Clinical Features

Abrupt onset of symptoms with prominent dyspnea

Fever, which is usually low grade

Cyanosis and diffuse crackles on lung auscultation

12-36% develop superinfections

Severe hypoxemia and infiltrates on chest imaging involving dependent pulmonary segments.

Abnormalities typically appear within two hours.

Bronchoscopy, if performed, demonstrates erythema of

the bronchi, indicating acid injury.

Aspiration pneumonitis

Treatment

Immediate tracheal suction if observed aspiration

Support pulmonary function.

Positive pressure ventilation,

High molecular weight colloids given intravenously

Sodium nitroprusside infused into the pulmonary artery.

Ventilation in patients with respiratory failure

Antibiotics if no infiltrates develop

Aspiration pneumonia

Clinical Features

Indolent symptoms

A predisposing condition for aspiration, usually compromised consciousness due to drug abuse, alcoholism, or anesthesia; or dysphagia

Absence of rigors

Failure to recover likely pulmonary pathogens with cultures of expectorated sputum

Sputum that often has a putrid odor

Concurrent evidence of periodontal disease

Radiograph or computed tomography (CT) scans showing evidence of pulmonary necrosis with lung abscess and/or an empyema

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Aspiration Pneumonia

Microbiology in CAP

Anerobes

Peptostreptococcus

Fusobacterium nucleatum

Prevotella

Bacteroides

Aerobic and Microaerophilic streptococci

Aspiration Pneumonia –

Microbiology in HAP

Anaerobes

Peptostreptococcus

Fusobacterium

nucleatum

Prevotella

Bacteroides

S.aureus

Gram negative bacill i

Pseudomonas aeruginosa

Acinetobacterbaumanii

Kelbsiella pneumonia

Escherichia coli

Aspiration Pneumonia

Treatment

Antibiotics

Depends upon risk factors, length of stay, history of

MDROs, ventilated etc

Duration: Not well studied ; 7-10 days

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Role of Sinusitis in VAP

Study suggests a link between the onset of sinusitis and the

development of VAP.

40% of patients with positive sinus cultures (42/105) exhibited the same microorganisms in bronchotracheal aspirates.

Early treatment of sinusitis may “significantly reduce the risk of VAP.”

http://ccforum.com/content/9/5/r583

Pneumonia: Prevention is Primary!

Prevention,

1 ounce=

Cure,

1 lb.

“Bundle Approach”requires 100% compliance on several key procedures

http://ccforum.com/content/9/5/r583

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Evidence-Based Strategies

for VAP Elimination

Component CDC APIC IHI AACN

Head of bed elevation (Semi-recumbent patient

positioning 30˚-45 ˚)

Daily “sedation vacation” and daily assessment of

readiness to extubate

Peptic ulcer disease (PUD) prophylaxis

Reliable, comprehensive oral hygiene program

Cleaning of equipment

Avoid routinely replacing ventilator circuits

Hand hygiene

Subglottic secretion drainage – continuous or

intermittent

Prevention of oropharyngeal colonization

IHI Getting Started Kit: VAP How-to Guide; CDC Guideline for Preventing Healthcare-Associated Pneumonia, 2002.

THE MOUTH’S ROLE IN

THE DEVELOPMENT OF HAP/VAP

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Oral Contribution to

Pneumonia

“that there was a distinct divergence between the oral bacteria of mechanically ventilated intensive care unit (ICU) patients who developed pneumonia and those who did not”

"In the case of hospitalized adults on mechanical ventilators, the change in bacteria preceded the development of pneumonia…"This suggests that changes in oral bacteria play a role in the risk for developing pneumonia.“

Samit Joshi, DO, MPH November 18, 2011

Ecology of the Mouth

Oral bacteria are usually “normal flora” with up

to 350 different species

Streptococcus mutans, Strep sanguis, Actinomyces vicosus and Bacteriodes gingivalis normally colonize teeth. Strep salivarius

colonizes dorsal tongue and S. mitis on buccal/teeth surfaces

Gibbons R. Bacterial adhesion to oral tissues: a model for infectious diseases. J Dent Res

1989;68(5):750-60.

The Tongue is Germ-laden

The dorsal posterior

aspect of the tongue

contains layers of

debris and harbors

millions of organisms.

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Within 48 hours

changes from

streptococci and

dental low virulence

pathogens to gram

negative organisms.

Munro, CL; and Grap MJ. Oral health measurement in nursing research: state of the science. Amer Jour Crit Care 2004,

13(1) 25-33.


Normal Saliva Functions

Washes unattached microorganisms from the mouth

Contains a number of immune substances which prevent colonization with pathogenic organisms:

immunoglobulin A obstructs microbial adherence in the oral cavity

lactoferrin which inhibits bacterial infection in the healthy individual

Bagg J. et al. The oral microflora and dental plaque. In: Essentials of microbiology for dental

students. Oxford: Oxford University Press; 1999. p. 229-310.


During critical illness

increased production of

proteases in oral

secretions removes the

glycoprotein – fibronectin

from cell surfaces

allows attachment of

gram-negative bacteria

such as Pseudomonas

aeruginosa to buccal and

pharyngeal cell surfaces

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Biofilm and plaque formation follow, allowing large amounts of microorganisms to be stored in the mouth

Bagg J. et al. The oral microflora and dental plaque. In: Essentials of Microbiology for Dental Students. Oxford:

Oxford University Press; 1999. p. 229-310.

Scanning electron micrograph of a Staphylococcal biofilm on the inner surface of an indwelling medical device.

Bar, 20 µm. Used with permission of Rodney M. Donlan, Ph.D. and Janice Carr, CDC

Xerostomia & Mucositis

Xerostomia, severely reduced salivary flow and dry mouth, is common in ICU patients due to fever, diarrhea, reduced intake and medication side effects

Mucositis, inflamation of oral mucus membranes, follows - resulting in increased oropharyngeal colonization with respiratory pathogens

Dennesen et al. Inadequate salivary flow and poor oral mucosal status in intubated intensive care unit patients. Crit Care Med 2003;31(3):781-786.

Impact of Salivary Flow on

Mucositis Development

0 7 14 21

0

25

20

15

10

5

Mu

co

sitis ind

ex

Days After Admission

Dennesen et al. Inadequate salivary flow and poor oral mucosal status in intubated intensive care unit

patients. Crit Care Med 2003; (31)3: 781-786.

↑ICU stay = ↓saliva↓saliva = ↑mucositis

0 7 14 21

0.0

2.5Sa

liva

ml/5

min

ute

s

Days After Admission

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Dental Plaque Development

↓saliva → ↑ mucositis

↑mucositis → ↑oral bacteria

↑oral bacteria →↑teeth biofilm/plaque

Dental Plaque Development

Beyond comfort: Oral hygiene as a critical nursing activity in the intensive care unit

Berry, AM, & Davidson, PM. Intensive and Critical Care Nursing; June 23, 2006.

If the intubated and/or

critically ill patient does not

receive effective oral

hygiene, then bacterial

plaque develops on the

teeth within 72 hours.

Suppressed Oral Functions

Secretions of mucosal resting

saliva + residue in the oral epithelium= sticky paste

Since the self-cleaning

function of the oral cavity is not working, the oral mucous membrane is not replaced.

Mucous remains on the palate and tongue becomes coated

http://www.med.or.jp/english/journal/pdf/2011_01/039_043.pdf

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As Dental Plaque Increases,

So Does the Risk of Pneumonia

Fourrier F. et al. Crit Care Med Feb 1998;26(2):301-308.

Damage to Oral Hard Tissue

Multiple cases of dental caries at the

tooth cervix

Crown may rot away with residual

roots left

Food adheres to root leading to

plaque

Bad breath pervades the entire

room = increased risk of aspiration pneumonia

http://www.med.or.jp/english/journal/pdf/2011_01/039_043.pdf

Optimal oral care

should focus on plaque

removal and stimulation

of salivary flow

Munro CL et al. Oral health status and development of VAP: a descriptive study. Am J Crit Care Sep 2006;15(5):453-459.

Comprehensive Oral Care Program

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Interventions Written oral care protocol

Staff education in comprehensive oral care

Conduct an initial admission assessment of the patient’s oral health and self-care deficits

Use a small, soft toothbrush

Brush teeth, tongue and gums at least twice daily to remove dental plaque

Foam swabs or gauze should not be used for plaque removal, as they are not effective tools for this task

Recommended Oral Care Interventions

for ALL Hospitalized Patients

Garcia R. A review of the possible role of oral and dental colonization on the occurrence of health care-associated

pneumonia: Underappreciated risk and a call for interventions. Am J Infect Control 2005;33:527-41.

Interventions Use an alcohol-free, antiseptic rinse

Use a water-soluble moisturizer to assist in the maintenance of healthy lips and gums at least once every two hours

Avoid using lemon-glycerin swabs for oral careto moisten oral mucosa

Recommended Oral Care Interventions

for ALL Hospitalized Patients



Additional Recommended Oral Care

for the Ventilated Patient

Interventions

Conduct an initial admission and daily assessment

of the lips, oral tissue, tongue, teeth, and saliva of

each patient on a mechanical ventilator

Keep head of bed elevated at least 300

- position patient so that oral secretions pool into the buccal pocket; especially important during feeding, brushing teeth, etc.



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Oral Decontamination

Routine oral decontamination

written policy and training should be in place

decontamination with an antiseptic agent

Chlorhexidine rinse recommended by many

CDC. Guidelines for Preventing Health-Care-Acquired Pneumonia Morbidity and Mortality Weekly Report, 2004; 53(rr-3

What about Chlorhexidine Gluconate

(CHG) Mouth Rinse?

Two meta-analyses report that although CHG may reduce the incidence of VAP, it doesn’t reduce time on the ventilator or lower the mortality rate.

Chan, E. Y., Ruest, A., Meade, M. O., and Cook, D. J. Oral decontamination for

prevention of pneumonia in mechanically ventilated adults: systematic review and

meta-analysis. BMJ 2007;334(7599):889-900.

Pineda, L. A., Saliba, R. G., and El Solh, A. A. Effect of oral decontamination with

chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Crit Care

2006. 10;1;R35-R41.

reallyDOES ORAL CARE ^ MAKE

A DIFFERENCE?

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Study Objectives:

To assess the oral status of patients in an ICU

Evaluate the effects of a defined oral care protocol on patients’ oral health

Fitch et al. Oral Care in the Adult Intensive Care Unit. American journal of Critical Care, Sept 1999, (8)5: 314-318

Question: What is the current practice of oral care in the Adult ICU?

STUDY #1

Findings:

1. Nurses have not been formally trained in assessing oral status of patients in

ICUs

2. Comprehensive Oral Care resulted in decreased oral inflammation,

candidiasis, purulence, bleeding, and plaque

Conclusion:

Implementation of a well-developed oral care protocol by bedside nurses can improve oral health of ICU patients

Fitch et al. American journal of Critical Care, (8)5: 314-318

What is the current practice of oral care in the Adult ICU?

STUDY #1

Background

All ventilator patients from Jan 2002-Dec 2002 received standard oral care –

yankauer suction and glycerin swabs

All ventilator patients from Jan 2003-Dec 2003 received comprehensive oral care, including daily oral assessment, teethbrushing, oral and orotracheal

suctioning, hydrogen peroxide rinse, oral mucosa moisturizer, and covered yankauer

Garcia R. Jendresky L, Colbert L. APIC 2004 Abstract.

Question: Does Reduction in Oral Microbial Colonization and Dental Plaque Reduce

VAPStudy #2

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Results

Rate of VAP was reduced 42.1% in the intervention group

Conclusion

Careful assessment and improved oral care reduces contaminated aspirates and subsequent VAP

Garcia R. Jendresky L, Colbert L. APIC 2004 Abstract.

Reduction in Oral Microbial Colonization and Dental Plaque Reduces VAP

Study #2

556 nurses surveyed

102 institutions

response rate of 83%

Furr,L.Allen; Binkley,C.J.; McCurren,C.; Carrico,R. J. Adv. Nurs 2004;48(5):454-456.

Factors Affecting Quality of Oral Care in ICUs

Study #3

FINDINGS:

Nurses need oral care education

Problem having sufficient time to provide care

Problem prioritizing oral care

View oral care as unpleasant



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CONCLUSION:

Improving oral care is a multi-layered task

RECOMMENDATIONS:

Reinforce proper oral care through education

De-sensitize nurses to the often-perceived unpleasantness of cleaning oral cavities

Monitor compliance and identify barriers to care



Questions?

Peggy Prinz Luebbert

MS,CIC,CHSP,CSPDT

Healthcare Interventions, Inc.

[email protected]

health goes south when pathogens and reflux linger in · pdf file9/19/2016 1 health goes south...

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