Oral care, ventilator-associated pneumonia, and counting cultures.

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2009, Volume 18, No. 6 507 Oral Care, Ventilator-Associated Pneumonia, and Counting Cultures There are plenty of opportunities for improvement in the field of health care–associated infection prevention. As a consequence, continuous educational efforts focused on cost-effective evidencebased strategies remain essential. This is also true for oral hygiene practice. A study by Grap et al revealed that the primary tools for performing oral care were sponge toothettes, although these are ineffective for removing dental plaque. Also, oral care practices are generally poorly documented in patient’s files. According to a European survey in 59 intensive care units (ICUs), 93% of nurses perceived oral hygiene in mechanically ventilated patients to be of high priority. However, 68% of nurses find cleaning the oral cavity in such patients difficult, 40% find it unpleasant, and 73% indicated they need better supplies and equipment. Clearly, the importance of oral hygiene to prevent ventilator-associated pneumonia should continuously be stressed by means of quality and/or research projects. Therefore, we were particularly interested in the article by Pedreira et al regarding oral care in intubated and mechanically ventilated pediatric patients. In a randomized controlled trial, these investigators compared the oropharyngeal microbiological profile between patients who received oral care with use of chlorhexidine 0.12% (n = 27) and a control group (n = 29). In both groups, strict toothbrushing was carried out. Oropharyngeal secretions were collected on days 0, 2, and 4, and at discharge, and were cultured for qualitative microbiological identification. The 2 groups did not differ significantly in the colonization of potentially pathogenic flora. These negative results are in contrast with other data that stress the added value of proper oral care and chlorhexidine as an antiseptic agent. An important concept in the pathogenesis of pneumonia is the strong relationship between the bacterial inoculum and the hazard of infection. In other words, whereas chlorhexidine oral washes failed to significantly reduce the number of colonizations by pathogenic microorganisms, it might have been successful in decreasing the bacterial load (lower bacterial counts with an identical number of isolates detected). In the study by Pedreira et al, oropharyngeal samples were collected, transported, and incubated in a strict standardized way. However, a qualitative culturing technique was used that indicates only the presence of microorganisms (colonization or not). We assume it must have been possible to report bacterial inoculums if quantitative cultures were used. In this way the study results may have turned out positive, even if one considers the small sample size. CHRISTELLE LIZY, RN, CCRN, NELE BRUSSELAERS, MD, SONIA LABEAU, RN, MNSC, DOMINIQUE VANDIJCK, RN, CCRN, MSC, PHD, DAVID DE WANDEL, RN, MSC, DIRK VOGELAERS, MD, PHD, STIJN BLOT, RN, CCRN, MNSC, PHD Ghent, Belgium