Less daily oral hygiene is more in the ICU: no

Wittekamp, Bastiaan H J; Plantinga, Nienke L.

doi:10.1007/s00134-021-06359-5

Cited by 7 publications

(9 citation statements)

References 18 publications

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“…This information is important for decision making around cohorting patients, de-escalation of PPE, and undertaking potential aerosol generating procedures, more so given the threat of new variants, such as Omicron, that have higher transmission rates and greater vaccine escape potential. It also supports the continued use of oral antiseptics in these patients; products such as chlorhexidine are used routinely to reduce the incidence of ventilator-associated pneumonia [34]. Our data suggests that they may also have a role to play in minimising nosocomial transmission, although formulations containing surfactants are likely to be more effective in this role than chlorhexidine [35].…”

Section: Discussionsupporting

confidence: 65%

Mechanically ventilated patients shed high titre live SARS-CoV2 for extended periods from both the upper and lower respiratory tract

Saud

Ponsford

Bentley

et al. 2021

Preprint

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Background SARS-CoV-2 infection can lead to severe acute respiratory distress syndrome needing intensive care admission and may lead to death. As a virus that transmits by respiratory droplets and aerosols, determining the duration of viable virus shedding from the respiratory tract is critical for patient prognosis, and informs infection control measures both within healthcare settings and the public domain. Methods We examined upper and lower airway respiratory secretions for both viral RNA and infectious virions in mechanically ventilated patients admitted to the intensive care unit of the University Hospital of Wales. Samples were taken from the oral cavity (saliva), oropharynx (sub-glottic aspirate), or lower respiratory tract (non-directed bronchoalveolar lavage (NBL) or bronchoalveolar lavage (BAL)) and analyzed by both qPCR and plaque assay. Results 117 samples were obtained from 25 patients. qPCR showed extremely high rates of positivity across all sample types, however live virus was far more common in saliva (68%) than in BAL/NBAL (32%). Average titres of live virus were higher in subglottic aspirates (4.5x10^7) than in saliva (2.2x10^6) or BAL/NBAL (8.5x10^6), and reached >10^8 PFU/ml in some samples. The longest duration of shedding was 98 days, while the majority of patients (14/25) shed live virus for 20 days or longer. Conclusions Intensive care unit patients infected with SARS-CoV-2 can shed high titres of virus both in the upper and lower respiratory tract, and tend to be prolonged shedders. This information is important for decision making around cohorting patients, de-escalation of PPE, and undertaking potential aerosol generating procedures.

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Section: Discussionsupporting

confidence: 65%

Mechanically ventilated patients shed high titre live SARS-CoV2 for extended periods from both the upper and lower respiratory tract

Saud

Ponsford

Bentley

et al. 2021

Preprint

View full text Add to dashboard Cite

show abstract

“…This information is important for decision making around cohorting patients, de-escalation of personal protective equipment, and undertaking potential aerosol-generating procedures, particularly given the threat of new variants such as Omicron that have higher transmission rates and greater vaccine escape potential. It also supports the continued use of oral antiseptics in these patients; antiseptics such as chlorhexidine are used routinely to reduce ventilator-associated pneumonia [ 29 ]. These may also have a role to play in minimizing nosocomial transmission, although formulations containing surfactants are likely to be most effective [ 30 ].…”

Section: Discussionmentioning

confidence: 91%

Mechanically Ventilated Patients Shed High-Titer Live Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) for Extended Periods From Both the Upper and Lower Respiratory Tract

Saud

Ponsford

Bentley

et al. 2022

Clinical Infectious Diseases

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Background SARS-CoV-2 infection can lead to severe acute respiratory distress syndrome needing intensive care admission and may lead to death. As a virus that transmits by respiratory droplets and aerosols, determining the duration of viable virus shedding from the respiratory tract is critical for patient prognosis, and informs infection control measures both within healthcare settings and the public domain. Methods We prospectively examined upper and lower airway respiratory secretions for both viral RNA and infectious virions in mechanically ventilated patients admitted to the intensive care unit of the University Hospital of Wales. Samples were taken from the oral cavity (saliva), oropharynx (sub-glottic aspirate), or lower respiratory tract (non-directed bronchoalveolar lavage (NBL) or bronchoalveolar lavage (BAL)) and analyzed by both qPCR and plaque assay. Results 117 samples were obtained from 25 patients. qPCR showed extremely high rates of positivity across all sample types, however live virus was far more common in saliva (68%) than in BAL/NBAL (32%). Average titres of live virus were higher in subglottic aspirates (4.5x10 7) than in saliva (2.2x10 6) or BAL/NBAL (8.5x10 6) and reached >10 8 PFU/ml in some samples. The longest duration of shedding was 98 days, while most patients (14/25) shed live virus for 20 days or longer. Conclusions Intensive care unit patients infected with SARS-CoV-2 can shed high titres of virus both in the upper and lower respiratory tract and tend to be prolonged shedders. This information is important for decision making around cohorting patients, de-escalation of PPE, and undertaking potential aerosol generating procedures.

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“…Research shows that routine practices indicated for de-adoption can persist, despite evidence of limited benefit or potential harm [ 14 ]. For example, clinician perceptions that chlorhexidine confers significant benefit, may contribute to concerns about withholding of this treatment and the need for an alternative course of action [ 15 , 16 ]. Recommended strategies to address this phenomenon include a rigorous de-adoption trial that removes one intervention (i.e., chlorhexidine) whilst advancing an alternative (i.e., standardized oral care bundle) that is consistent with ethical and evidence-based practice.…”

Section: Introductionmentioning

confidence: 99%

Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): a multi-center stepped wedge cluster-randomized controlled trial

et al. 2021

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Purpose Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients. Methods A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors. Results A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period. Conclusion Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06475-2.

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Less daily oral hygiene is more in the ICU: no

Cited by 7 publications

References 18 publications

Mechanically ventilated patients shed high titre live SARS-CoV2 for extended periods from both the upper and lower respiratory tract

Mechanically ventilated patients shed high titre live SARS-CoV2 for extended periods from both the upper and lower respiratory tract

Mechanically Ventilated Patients Shed High-Titer Live Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) for Extended Periods From Both the Upper and Lower Respiratory Tract

Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): a multi-center stepped wedge cluster-randomized controlled trial

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