EFFECT OF ORAL ANTISEPTICS ON PREVENTION OF VENTILATOR-ASSOCIATED PNEUMONIA: A BIBLIOMETRIC STUDY

Abstract

Aim: Ventilator-associated pneumonia (VAP) is an important nosocomial infection in mechanically ventilated patients in intensive care units and increases morbidity, mortality, and length of hospital stay. Maintenance of oral hygiene is a widely used preventive measure to reduce the incidence of VAP; however, the efficacy of antiseptic agents such as chlorhexidine (CHX) has shown contradictory results in the literature. This study aims to evaluate the effects of CHX and alternative antiseptic agents on the incidence of VAP, mortality, and length of hospital stay through bibliometric analysis and to determine scientific research trends in this area. Materials and Methods: This bibliometric analysis was conducted by systematically searching the Web of Science, Scopus, Embase, and PubMed databases for studies published between 2000 and 2024. Inclusion criteria included randomized controlled trials (RCTs) investigating the effects of oral antiseptics on ventilator-associated pneumonia. Results: The analyzed studies showed that CHX reduces the incidence of VAP in some cases, while no significant effect is found in others. Among the alternative agents, ozonated water, povidone-iodine and herbal-based mouthwashes showed similar or greater efficacy in preventing VAP. The findings suggest that the use of CHX alone may not be sufficient in VAP prevention protocols and that alternative antiseptic agents should be considered. In particular, ozonated water and povidone-iodine and herbal-based agents may be promising in reducing the incidence of VAP. Conclusion: The results of the bibliometric analysis indicate an increasing trend in the research of oral antiseptics in VAP prevention and emphasize the need for larger-scale, multicenter randomized controlled trials using common methodology in the future.

Keywords

• Intensive care unit
• Ventilator-associated pneumonia
• Antiseptic mouthwashes
• Oral hygiene
• Dental plaque colonization

Oral Antiseptiklerin Ventilatör İlişkili Pnömoninin Önlenmesine Etkisi: Bibliyometrik Çalışma

Abstract

Amaç: Ventilatörle ilişkili pnömoni (VAP), yoğun bakım ünitelerinde mekanik ventilasyon uygulanan hastalarda önemli bir nozokomiyal enfeksiyon olup morbidite, mortalite ve hastanede yatış süresini artırmaktadır. Ağız hijyeninin sağlanması, VAP insidansını azaltmak için yaygın olarak kullanılan bir önlem olmakla birlikte, klorheksidin (CHX) gibi antiseptik ajanların etkinliği konusunda literatürde çelişkili sonuçlar mevcuttur. Bu çalışmanın amacı, CHX ve alternatif antiseptik ajanların VAP insidansı, mortalite ve hastanede kalış süresi üzerindeki etkilerini bibliyometrik analiz yöntemiyle incelemek ve alandaki bilimsel araştırma eğilimlerini belirlemektir. Gereç ve Yöntem: Bu bibliyometrik analiz, 2000-2024 yılları arasında Web of Science, Scopus ve PubMed veri tabanlarında yayımlanan çalışmaların sistematik olarak taranmasıyla gerçekleştirilmiştir. Dahil edilme kriterleri, ventilatörle ilişkili pnömoni üzerine ağız antiseptiklerinin etkisini inceleyen randomize kontrollü çalışmalar (RKÇ)’dır. Bulgular: Analiz edilen çalışmalar, CHX’in bazı durumlarda VAP insidansını azalttığını gösterirken, bazı çalışmalarda anlamlı bir etkisinin olmadığını ortaya koymuştur. Alternatif ajanlar arasında ozonlu su, povidon-iyod ve bitkisel içerikli gargaraların VAP önlenmesinde benzer veya daha fazla etkinlik gösterdiği belirlenmiştir. Elde edilen bulgular, VAP önleme protokollerinde tek başına CHX kullanımının yeterli olmayabileceğini ve alternatif antiseptik ajanların değerlendirilmesi gerektiğini göstermektedir. Özellikle ozonlu su, povidon-iyot ve bitrkisel içerikli ajanlar VAP insidansını azaltma konusunda umut verici olabilir. Sonuç: Bibliyometrik analiz sonuçları, VAP önlenmesine yönelik araştırmaların giderek artan bir eğilim gösterdiğini ve gelecekte daha büyük ölçekli, ortak metodoloji kullanan, çok merkezli randomize kontrollü çalışmaların yapılmasının gerekliliğini ortaya koymaktadır.

Keywords

• Yoğun bakım ünitesi
• Ventilatörle ilişkili pnömoni,
• Antiseptik gargaralar
• Ağız hijyeni
• Diş plağı kolonizasyonu

References

1. Hutchins, K., Karras, G., Erwin, J., & Sullivan, K. L. (2009). Ventilator-associated pneumonia and oral care: A successful quality improvement project. American Journal of Infection Control, 37(7), 590-597.
2. Emori, T. G., Culver, D. H., Horan, T. C., Jarvis, W. R., White, J. W., Olson, D. R., et al. (1991). National nosocomial infections surveillance system (NNIS): Description of surveillance methods. American Journal of Infection Control, 19(1), 19-35.
3. Johanson, W. G. Jr., Pierce, A. K., Sanford, J. P., & Thomas, G. D. (1972). Nosocomial respiratory infections with gram-negative bacilli: The significance of colonization of the respiratory tract. Annals of Internal Medicine, 77(5), 701-706.
4. Gasink, L. B., Edelstein, P. H., Lautenbach, E., Synnestvedt, M., & Fishman, N. O. (2009). Risk factors and clinical impact of Klebsiella pneumoniae carbapenemase- producing K. pneumoniae. Infection Control and Hospital Epidemiology, 30(12), 1180-1185.
5. Nobahar, M., Razavi, M. R., Malek, F., & Ghorbani, R. (2016). Effects of hydrogen peroxide mouthwash on preventing ventilator- associated pneumonia in patients admitted to the intensive care unit. Brazilian Journal of Infectious Diseases, 20(5), 444- 450.
6. Tuon, F. F., Gavrilko, O., Almeida, S., Sumi, E. R., Alberto, T., Rocha, J. L., et al. (2017). Prospective, randomised, controlled study evaluating early modification of oral microbiota following admission to the intensive care unit and oral hygiene with chlorhexidine. Journal of Global Antimicrobial Resistance, 8, 159-163.
7. Karakaya, Z., Duyu, M., & Yersel, M. N. (2022). Oral mucosal mouthwash with chlorhexidine does not reduce the incidence of ventilator-associated pneumonia in critically ill children: A randomised controlled trial. Australian Critical Care, 35(4), 336-344.
8. Ebrahimian, A., Ghorbani, R., Alishah, M., Zamani-Kiasari, A., Kianvash-Rad, N., & Nobahar, M. (2019). The effect of Zufa versus chlorhexidine gluconate mouthwashes on oral flora of patients under mechanical ventilation in the intensive care unit: A double-blind, randomized clinical trial. Iranian Red Crescent Medical Journal, 21(5).

9. Özden, D., Türk, G., Düger, C., Güler, E. K., Tok, F., & Gülsoy, Z. (2014). Effects of oral care solutions on mucous membrane integrity and bacterial colonization. Nursing in Critical Care, 19(2), 78-86.
10. Bellissimo-Rodrigues, W. T., Menegueti, M. G., de Macedo, L. D., Basile-Filho, A., Martinez, R., & Bellissimo-Rodrigues, F. (2019). Oral mucositis as a pathway for fatal outcome among critically ill patients exposed to chlorhexidine: Post hoc analysis of a randomized clinical trial. Critical Care, 23(1), 382.
11. Zarinfar, N., Ghaznavi-Rad, E., Mahmoodiyeh, B., & Reyhani, A. (2021). Comparison of three interventional approaches to prevent ventilator-associated pneumonia in intensive care units (ICUs): A clinical trial study. Qatar Medical Journal, 2021(2), 21.
12. Meidani, M., Khorvash, F., Abbasi, S., Cheshmavar, M., & Tavakoli, H. (2018). Oropharyngeal irrigation to prevent ventilator- associated pneumonia: Comparing potassium permanganate with chlorhexidine. International Journal of Preventive Medicine, 12(9), 93.
13. Azimi, M., Jouybari, L., Moghadam, S., Ghaemi, E., Behnampoor, N., Sanagoo, A., & Hesam, M. (2016). Antimicrobial effects of chlorhexidine, matrica drop mouthwash (chamomile extract), and normal saline on hospitalized patients with endotracheal tubes. Iranian Journal of Nursing and Midwifery Research, 21(5), 458-463.
14. Genuit, T., Bochicchio, G., Napolitano, L. M., McCarter, R. J., & Roghman, M. C. (2001). Prophylactic chlorhexidine oral rinse decreases ventilator-associated pneumonia in surgical ICU patients. Surgical Infections, 2(1), 5-18.
15. Berry, A. M. (2013). A comparison of Listerine and sodium bicarbonate oral cleansing solutions on dental plaque colonisation and incidence of ventilator associated pneumonia in mechanically ventilated patients: A randomised control trial. Intensive and Critical Care Nursing, 29(5), 275-281.
16. Özçaka, Ö., Başoğlu, O. K., Buduneli, N., Taşbakan, M. S., Bacakoğlu, F., & Kinane, D. F. (2012). Chlorhexidine decreases the risk of ventilator-associated pneumonia in intensive care unit patients: A randomized clinical trial. Journal of Periodontal Research, 47(5), 584-592.
17. Berry, A. M., Davidson, P. M., Masters, J., Rolls, K., & Ollerton, R. (2011). Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator-associated pneumonia in mechanically ventilated patients: A randomized control trial. International Journal of Nursing Studies, 48(6), 681-688.
18. Bellissimo-Rodrigues, F., Viana, J. M., Teixeira, G. C., Nicolini, E., Martins, M. A., Passos, A. D., et al. (2009). Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infection Control and Hospital Epidemiology, 30(10), 952-958.
19. Scannapieco, F. A., Yu, J., Raghavendran, K., Vacanti, A., Owens, S. I., Wood, K., et al. (2009). A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Critical Care, 13(4), R117.
20. Tantipong, H., Morkchareonpong, C., Jaiyindee, S., & Thamlikitkul, V. (2008). Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infection Control and Hospital Epidemiology, 29(2), 131-136.
21. Panchabhai, T. S., Dangayach, N. S., Krishnan, A., Kothari, V. M., & Karnad, D. R. (2009). Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: An open-label randomized trial with 0.01% potassium permanganate as control. Chest, 135(5), 1150-1156.
22. Jahanshir, M., Nobahar, M., Ghorbani, R., & Malek, F. (2023). Effect of clove mouthwash on the incidence of ventilator-associated pneumonia in intensive care unit patients: A comparative randomized triple- blind clinical trial. Clinical Oral Investigations, 27(7), 3589-3600.
23. Izadi, M., Bagheri, M., Bahrami Far, A., Bagheri-Baghdasht, M. S., Ghasemzadeh, G., Sureda, A., & Soodmand, M. (2023). Reduce the risk of ventilator-associated pneumonia in ICU patients by ozonated water mouthwash: A double-blind randomized clinical trial. American Journal of Infection Control, 51(7), 779-785.
24. Siriyanyongwong, P., Teanpaisan, R., Pahumunto, N., Uppanisakorn, S., & Vattanavanit, V. (2022). Efficacy of Moraceae with chlorhexidine mouthwash on the microbial flora of critically ill intubated patients: A randomized controlled pilot study. Scientific Reports, 12(1), 17261.
25. Seguin, P., Laviolle, B., Dahyot-Fizelier, C., Dumont, R., Veber, B., Gergaud, S., Asehnoune, K., Mimoz, O., Donnio, P. Y., Bellissant, E., Malledant, Y., SPIRIT ICU Study Group, & AtlanRéa Group. (2014). Effect of oropharyngeal povidone-iodine preventive oral care on ventilator-associated pneumonia in severely brain-injured or cerebral hemorrhage patients: A multicenter, randomized controlled trial. Critical Care Medicine, 42(1), 1-8.
26. Seguin, P., Tanguy, M., Laviolle, B., Tirel, O., & Mallédant, Y. (2006). Effect of oropharyngeal decontamination by povidone-iodine on ventilator-associated pneumonia in patients with head trauma. Critical Care Medicine, 34(5), 1514-1519.
27. Chua, J., Dominguez, E. A., Sison, C. M., & Berba, R. P. (2005). The efficacy of povidone- iodine oral rinse in preventing ventilator- associated pneumonia: A randomized, double-blind, placebo-controlled (VAPOR) trial. Philippine Journal of Internal Medicine, 43(1), 1-8.
28. Fourrier, F., Dubois, D., Pronnier, P., Herbecq, P., Leroy, O., Desmettre, T., Pottier- Cau, E., Boutigny, H., Di Pompéo, C., Durocher, A., & Roussel-Delvallez, M., PIRAD Study Group. (2005). Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: A double-blind placebo-controlled multicenter study. Critical Care Medicine, 33(8), 1728-1735.
29. Fourrier, F., Cau-Pottier, E., Boutigny, H., Roussel-Delvallez, M., Jourdain, M., & Chopin, C. (2000). Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Medicine, 26(9), 1239-1247.
30. Koeman, M., van der Ven, A. J., Hak, E., Joore, H. C., Kaasjager, K., de Smet, A. G., Ramsay, G., Dormans, T. P., Aarts, L. P., de Bel, E. E., Hustinx, W. N., van der Tweel, I., Hoepelman, A. M., & Bonten, M. J. (2006). Oral decontamination with chlorhexidine reduces the incidence of ventilator- associated pneumonia. American Journal of Respiratory and Critical Care Medicine, 173(12), 1348-1355.
31. Pittet, D. (2000). Improving compliance with hand hygiene in hospitals. Infection Control and Hospital Epidemiology, 21(6), 381-386.
32. Bouglé, A., Bombled, C., Margetis, D., Lebreton, G., Vidal, C., Coroir, M., Hajage, D., & Amour, J. (2018). Ventilator-associated pneumonia in patients assisted by veno-arterial extracorporeal membrane oxygenation support: Epidemiology and risk factors of treatment failure. PLoS One, 13(4), e0194976.
33. Sole, M. L., Poalillo, F. E., Byers, J. F., & Ludy, J. E. (2002). Bacterial growth in secretions and on suctioning equipment of orally intubated patients: A pilot study. American Journal of Critical Care, 11(2), 141-149.
34. Coleman, P. (2002). Improving oral health care for the frail elderly: A review of widespread problems and best practices. Geriatric Nursing, 23(4), 189-199.