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What’s New in the
Patient Safety World
February 2024
Remember the
Toothbrush!
Our June 2022 What's New in the Patient Safety World “Guideline
Update: Preventing Hospital-Acquired Pneumonia” reported on the 2022 update of “Strategies to prevent
ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care
hospitals” (Klompas
2022). This is the first
update since 2014 and is the collaborative work of the Society for Healthcare
Epidemiology (SHEA), the Infectious Diseases Society of America (IDSA), the
American Hospital Association, the Association for Professionals in Infection
Control and Epidemiology, and The Joint Commission. Representatives from
multiple other organizations and societies also contributed.
One of the items
listed under “major changes” was a recommendation for daily toothbrushing. The
recommendation for daily toothbrushing for prevention of VAP was based on
moderate evidence. Though there was less evidence for daily toothbrushing for
prevention of non-ventilatory hospital-acquired pneumonia (NVHAP), it was still
recommended as a practical intervention.
A new systematic review and meta-analysis (Ehrenzeller
2023) of studies assessing the impact of daily toothbrushing on
hospital-acquired pneumonia (HAP) included 15 trials with a total of 10,742
patients (2033 in the ICU and 8709 in non-ICU locations). Toothbrushing was
associated with significantly lower risk for HAP (risk ratio 0.67) and ICU
mortality (RR 0.81). Reduction in pneumonia incidence was significant for
patients receiving invasive mechanical ventilation (RR 0.68) but not for
patients who were not receiving invasive mechanical ventilation (RR 0.32). Toothbrushing
for patients in the ICU was also associated with fewer days of mechanical
ventilation (mean difference, −1.24 days) and a shorter ICU length of
stay (mean difference, −1.78 days). Brushing twice a day vs more frequent
intervals was associated with similar effect estimates. Non-ICU hospital length
of stay and use of antibiotics were not associated with toothbrushing.
The authors conclude that these findings suggest that
routine toothbrushing should be considered an essential component of standard
care in hospitalized patients, particularly in patients receiving invasive mechanical
ventilation.
However, as pointed out in the accompanying editorial (Datta
2023), there is still uncertainty regarding the role of daily toothbrushing
in NV-HAP. Ehrenzeller and Klompas could only
identify 2 studies with nonventilated patients that met their inclusion
criteria. Among these, the effect estimate suggested toothbrushing could
prevent NV-HAP, but the small sample size and wide confidence interval
underscore the need for more data on NV-HAP.
The new study adds credence to the importance of maintaining
oral hygiene in hospitalized patients.
Some of our prior
columns on HAI’s (hospital-acquired infections):
December 28, 2010 “HAI’s: Looking In All The Wrong Places”
October 2013 “HAI’s:
Costs, WHO Hand Hygiene, etc.”
February 2015 “17% Fewer HAC’s: Progress or Propaganda?”
April 2016 “HAI’s:
Gaming the System?”
September 2016 “More
on Preventing HAI’s”
November 2018 “Privacy
Curtains Shared Rooms and HAI’s”
December 2018 “HAI
Rates Drop”
January 2019 “Oral
Decontamination Strategy Fails”
February 2019 “Infection
Prevention for Anesthesiologists”
March 2019 “Does
Surgical Gowning Technique Matter?”
May 2019 “Focus
on Prophylactic Antibiotic Duration”
July 2019 “HAI’s
and Nurse Staffing”
February 2020 “NICU:
Decolonize the Parents”
June 16, 2020 “Tracking Technologies”
August 2020 “Surgical
Site Infections and Laparoscopy”
December 2020 “Do
You Have These Infection Control Vulnerabilities?”
May 2021 “CLABSI’s
Up in the COVID-19 Era”
August 2021 “Updated
Guidelines on C. diff”
October 2021 “HAI’s
Increase During COVID-19 Pandemic”
June 2022 “Guideline
Update: Preventing Hospital-Acquired Pneumonia”
June 21, 2022 “Preventing Post-op Pneumonia”
June 28, 2022 “Pneumonia in Nervous System
Injuries”
August 2022 “Resistant
Infections Up During COVID-19 Pandemic”
November 15, 2020 “Which Antiseptic?”
December 2022 “Game
Changer to Prevent SSI’s in Abdominal Surgery?”
May 30, 2023 “Non-Ventilator-Hospital-Acquired
Pneumonia Finally Gets Attention”
August 2023 “New
MRSA Guidelines”
September 12, 2023 “Radiology and
Hospital-Acquired Infections”
January 2024 “HAI’s
Drop Sharply Post-Pandemic”
References:
Klompas M, Branson R, Cawcutt K, et al.. Strategies to prevent
ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care
hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 20: 1-27
Ehrenzeller S, Klompas M.
Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia: A
Systematic Review and Meta-Analysis. JAMA Intern Med 2023; Published online
December 18, 2023
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2812938
Datta R. Daily Toothbrushing to Prevent Hospital-Acquired
Pneumonia—Brushing Away the Risk. JAMA Intern Med 2023; Published online
December 18, 2023
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2812944?resultClick=1
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What’s New in
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