Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study

OBJECTIVE: To document the effect of gingival and dental plaque antiseptic decontamination on the rate of nosocomial bacteremias and respiratory infections acquired in the intensive care unit (ICU). DESIGN: Prospective, multicenter, double-blind, placebo-controlled efficacy study. SETTING: Six ICUs: three in university hospitals and three in general hospitals. PATIENTS: A total of 228 nonedentulous patients requiring endotracheal intubation and mechanical ventilation, with an anticipated length of stay > or =5 days. INTERVENTIONS: Antiseptic decontamination of gingival and dental plaque with a 0.2% chlorhexidine gel or a placebo gel, three times a day, during the entire ICU stay. MEASUREMENTS AND MAIN RESULTS: Demographic and clinical characteristics, organ function data (Logistic Organ Dysfunction score), severity of condition (Simplified Acute Physiologic Score), and dental plaque status were assessed at baseline and until 28 days. Bacteriologic sampling of dental plaque and saliva was done every 5 days, and blood, tracheal aspirate, and bronchoalveolar lavage cultures were performed when appropriate. The primary efficacy end point was the incidence of bacteremia, bronchitis, and ventilator-associated pneumonia, expressed as a percentage and per 1000 ICU days. All baseline characteristics were similar between the treated and the placebo groups. The incidence of nosocomial infections was 17.5% (13.2 per 1000 ICU days) in the placebo group and 18.4% (13.3 per 1000 ICU days) in the plaque antiseptic decontamination group (not significant). No difference was observed in the incidence of ventilator-associated pneumonia per ventilator or intubation days, mortality, length of stay, and care loads (secondary end points). On day 10, the number of positive dental plaque cultures was significantly lower in the treated group (29% vs. 66%; p < .05). Highly resistant Pseudomonas, Acinetobacter, and Enterobacter species identified in late-onset ventilator-associated pneumonia and previously cultured from dental plaque were not eradicated by the antiseptic decontamination. No side effect was reported. CONCLUSIONS: Gingival and dental plaque antiseptic decontamination significantly decreased the oropharyngeal colonization by aerobic pathogens in ventilated patients. However, its efficacy was insufficient to reduce the incidence of respiratory infections due to multiresistant bacteria.     

Intérêt des soins de bouche et du brossage des dents dans la prévention des pneumonies acquises sous ventilation mécanique

Among preventive measures suggested to reduce the incidence of ventilator associated pneumonia (VAP), regular oral care is included in most of the ventilator care bundles. This nursing care usually includes oral rinses with antiseptic solutions, especially with chlorhexidine at different levels of concentration, tooth brushing, associated with repeated oral aspirations. The rational is based on VAP physiopathology: Most of microorganisms responsible for VAP come from oropharyngeal cavity and dental plaque: Oral care with chlorhexidine or other antiseptic and tooth brushing decrease bacterial colonization at this localization. If randomized trials show positive results in cardiac surgery patients, results are more conflicting in other ICU populations. Meta-analyses confirm these results with a probable but modest preventive effect, mainly in cardiac surgery patients, and they show no additional effect of tooth brushing, nor any impact on mortality, duration of mechanical ventilation or length of stay. Oral care is preeminently a basic hygiene and wellbeing care, and plays a minor role in VAP prevention.     

Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis

Introduction  

Nosocomial pneumonia is a significant cause of in-hospital morbidity and mortality. Oral care interventions have great potential to reduce the occurrence of nosocomial pneumonia. Studies using topical antiseptic agents yielded mixed results. We hypothesized that the use of chlorhexidine for oral decontamination would reduce the incidence of nosocomial pneumonia in patients requiring mechanical ventilation.     

创伤患者住ICU期间发生院内感染的危险因素分析

目的 探讨导致创伤患者在重症监护病房期间发生院内感染的危险因素.方法 回顾性分析了2009年1月1日至12月31日浙江省5家医院1103名创伤患者的相关资料,通过对16项可能和发生感染的相关因素的单因素以及多因素分析,最终筛选出导致所有创伤患者以及严重创伤患者住ICU期间发生感染的独立危险因素.结果 住ICU期间共有171人(15.5%)发生感染.患者总共死亡157人(14.2%),其中感染组死亡59人.感染组病死率为34.7%,显著高于非感染组的10.5%.多因素logistic回归分析结果提示,对于所有患者而言,中心静脉压监测、机械通气、年龄≥65岁、住ICU时间>14 d以及ISS≥16分为住ICU期间发生院内感染的独立危险因素.对于严重创伤患者,中心静脉压监测、机械通气以及住ICU时间>14 d则是其独立危险因素.结论 伤情严重程度、年龄、住ICU时间以及ICU内侵入性操作与创伤患者住ICU期间发生院内感染相关,规范各种侵入性操作以及尽量减少患者住ICU时间有助于降低患者发生院内感染的机率.

Abstract：

Objective To determine risk factors in nosocomial infection of trauma patients during intensive care unit stay. Methods A retrospective study was carried out. A total of 1103 trauma patients admitted to the intensive care unit of five tertiary hospitals in Zhejiang Province in 2009 were reviewed. Demographic data, injury severity score and other variables related to the trauma services were collected. Univariate and multivariate analysis were processed to identify the independent risk factors of nosocomial infection in trauma patients during stay in intensive care unit. Results Overall, 171 patients( 15.5% )developed nosocomial infection during ICU stay. Of 1103 patients, 157 patients (14.2% ) died, and the 59 fatal patients were from infection group. The mortality rate in infection group was 34.7% , which was significantly higher than that in non - infection group (10.5% ). The independent risk factors of nosocomial infection in all the patients determined by using multivariate analysis included central venous monitoring, mechanical ventilation, age ≥65, the length of ICU stay > 14 days and injury severity score ≥ 16. For the severe trauma patients, central venous monitoring, mechanical ventilation, the length of ICU stay > 14 days were independent risk factors of nonsocomial infection. Conclusions The severity of injury, age, the length of ICU stay and invasive procedures were related to the nosocomial infection. To standardize the invasive procedures and to reduce the length of ICU stay may decrease the infection rate of trauma patients.     

重症监护室囊上冲洗联合氯己定口腔护理预防呼吸机相关性肺炎的效果评价

[目的]探讨呼吸道囊上分泌物冲洗联合氯己定口腔护理能否降低呼吸机相关性肺炎(VAP)的发生率。[方法]选择124例于重症监护室(ICU)住院治疗并行气管插管或气管切开的病人,随机分为对照组和实验组,均执行常规气道护理及持续呼吸道分泌物囊上吸引。对照组病人给予生理盐水棉球口腔护理,每日2次;实验组病人在口腔护理前先行囊上分泌物冲洗,后以0.12%氯己定棉球进行口腔护理,每日2次。比较两组病人ICU住院时间、机械通气时间、痰液培养结果及VAP发生率。[结果]两组病人ICU住院时间、机械通气时间、VAP发生率比较差异有统计学意义(P<0.05)。[结论]呼吸道分泌物囊上冲洗配合氯己定口腔护理能缩短病人ICU住院时间及机械通气时间、降低VAP发生率。     

Colonization of dental plaque by respiratory pathogens in medical intensive care patients.

OBJECTIVE: To assess the prevalence of oral colonization by respiratory pathogens in a group of ICU patients, with specific attention to dental plaque and the oral mucosa. DESIGN: Prospective, nonrandomized study with age-matched controls. SETTINGS: Medical ICU in a tertiary-care Veterans Affairs Medical Center and a dental school outpatient preventive dentistry clinic. PATIENTS: Nonconsecutive, unselected patients admitted to the medical ICU during a 2-month period; controls were age-matched patients seen for the first time in the preventive dentistry clinic. INTERVENTIONS: None. MEASUREMENTS: Oral hygienic status was assessed in both groups using a semiquantitative system. Quantitative cultures of dental plaque and buccal mucosa were done within 12 hrs of medical ICU admission and every third day thereafter until discharge/death from the medical ICU. In controls, cultures of plaque and buccal mucosa were done on the initial visit only. Severity of illness of medical ICU patients was quantitated using the Acute Physiology and Chronic Health Evaluation (APACHE II) system and McCabe-Jackson criteria. MAIN RESULTS: Oral hygiene of medical ICU patients was poor. These patients had a mean plaque score (1.9 +/- 0.2) that was significantly greater than that same score seen in outpatients of the preventive dentistry clinic (1.4 +/- 0.1; p less than .005). Plaque and/or oral mucosa of 22 (65%) of 34 medical ICU patients were colonized by respiratory pathogens, in contrast to only four (16%) of 25 preventive dentistry clinic patients (p less than .005). The potential respiratory pathogens cultured from medical ICU patients included methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and ten genera of Gram-negative bacilli. Colonization by respiratory pathogens was statistically associated with concomitant antibiotic therapy within the medical ICU group of patients, but not with severity of illness. Although medical ICU patients tended to have more dental plaque than preventive dentistry clinic patients, there was no statistically significant association noted between the presence of dental plaque and respiratory pathogen colonization. CONCLUSIONS: These findings suggest that bacteria commonly causing nosocomial pneumonia colonize the dental plaque and oral mucosa of intensive care patients. In many cases, this colonization occurs by large numbers of bacteria. Dental plaque may be an important reservoir of these pathogens in medical ICU patients. Efforts to improve oral hygiene in medical ICU patients could reduce plaque load and possibly reduce oropharyngeal colonization.     

A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens

OBJECTIVE: Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes. DESIGN: Retrospective cohort study. SETTING: Inner-city municipal hospital. PATIENTS: Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal. INTERVENTIONS: Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital. MEASUREMENTS AND MAIN RESULTS: Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17% were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21% p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58%; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22%; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia. CONCLUSIONS: Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.     

Oral Care Reduces Incidence of Ventilator-Associated Pneumonia in ICU Populations

OBJECTIVE: To examine whether oral care contributes to preventing ventilator-associated pneumonia (VAP) in ICU patients. DESIGN: Nonrandomized trial with historical controls. SETTING: A medical-surgical ICU in a university hospital. PATIENTS: 1,666 mechanically ventilated patients admitted to the ICU. INTERVENTION: Oral care was provided to 1,252 patients who were admitted to the ICU during period between January 1997 and December 2002 (oral care group), while 414 patients who were admitted to the ICU during period between January 1995 and December 1996 and who did not receive oral care served as historical controls (non-oral care group). MEASUREMENTS AND RESULTS: Incidence of VAP(episodes of pneumonia per 1000 ventilator days) in the oral care group was significantly lower than that in the non-oral care group (3.9 vs 10.4). The relative risk of VAP in the oral care group compared to that in the non-oral care group was 0.37, with an attributable risk of -3.96%. Furthermore, length of stay in ICU before onset of VAP was greater in the oral care than in the non-oral care group (8.5+/-4.6 vs 6.3+/-7.5 days). However, no significant difference was observed in either duration of mechanical ventilation or length of stay between the groups (5.9+/-10.8 vs 6.0+/-8.8 days and 7.5+/-11.5 vs 7.2+/-9.5 days, respectively). Pseudomonoas aeruginosa was the most frequently detected bacteria in both groups. Number of potentially pathogenic bacteria in oral cavity was significantly reduced by single oral care procedure. CONCLUSION: Oral care decreased the incidence of VAP in ICU patients. DESCRIPTOR: Pulmonary nosocomial infection.     

Oral care and oropharyngeal and tracheal colonization by Gram-negative pathogens in children

Background: Critical care nursing interventions to oral care can reduce microorganisms in the oropharynx available for translocation. Objectives: To analyse the effect of 0·12% chlorhexidine digluconate on the colonization of oropharyngeal and tracheal secretions by Gram‐negative pathogens in mechanically ventilated children. Methods: A randomized, controlled and double‐blinded study was performed in the paediatric intensive care unit (PICU) of a Brazilian university hospital. Exclusion criteria included child age under 28 days, pneumonia diagnosis at admission, use of tracheostomy, PICU length of stay (LOS) less than 48 h and refusal to participate. Children were randomly allocated to the interventional group (IG), in which oral care with chlorhexidine was administered, or to the placebo group (PG), which received oral care without antiseptic use. The data were analysed through Pearson's χ² test, Fisher's exact and ANOVA tests with significance levels set at 0·05. Results: The demographic characteristics of the 74 children were not statistically different between groups. No between‐group differences in oropharyx colonization by Gram‐negative pathogens were identified (p = 0·316). Pathogens were isolated in the tracheal secretions of two (10·0%) children in the PG and four (19·0%) children in the IG (p = 0·355). Conclusion: The use of chlorhexidine did not significantly influence the colonization of oropharyngeal and tracheal secretions by Gram‐negative pathogens of the studied sample. Relevance to clinical practice: This study demonstrated no influence of a specific antiseptic agent on colonization profile of mechanically ventilated children in PICU. Further research in this field is necessary to promote evidence‐based nursing practice on oral care of critically ill children.     

Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination (SOD)

Abstract Objective: To determine the influence of selective oropharyngeal decontamination (SOD) on the rate of colonization and infection of the respiratory tract in intensive care patients requiring mechanical ventilation for more than 4 days. A financial assessment was also performed. Design: Randomized, prospective, controlled study using amphotericin B, colistin sulfate (polymyxin E), and tobramycin applied to the oropharynx and systemic cefotaxime prophylaxis. Setting: Anesthesiology intensive care unit (ICU) of a 1500-bed hospital. Patients: A total of 88 patients admitted as emergencies and intubated within less than 24 h were enrolled. Fifty- eight patients received SOD and 30 patients served as controls. Randomization was in the proportion of 2 : 1 study patients to controls. Interventions: Microbiological samples from the oropharynx and other infected sites were taken at the time of admission, then twice a week and after extubation. Measurements and results: With the use of SOD, colonization was significantly reduced. Furthermore, the infection rate decreased from 77 % in the controls to 22 % in the study patients. Staphylococcus aureus was the main potential pathogen causing colonization and pneumonia. Number of days in the ICU, duration of ventilation, and mortality were not significantly decreased. The total cost of antibiotics was reduced. Development of resistance was not observed. Conclusions: The use of SOD significantly reduced the colonization and pneumonia and the total charge for antibiotics. The length of stay in the ICU, duration of ventilation, and mortality were similar. No resistance was observed. Staphylococcus aureus was selected by SOD in some patients and the clinical relevance needs further observation. Received: 5 March 1996 Accepted: 24 October 1996     

Effects of a multifaceted,multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation

OBJECTIVE: To examine the effects of a mechanical ventilation weaning management protocol that was implemented as a hospital-wide, quality improvement program on clinical and economic outcomes. DESIGN: Prospective, before-and-after intervention study. Data from a preimplementation year are compared with those of the first 2 yrs after protocol implementation. PATIENTS AND SETTING: Patients older than 18 yrs in diagnosis-related group 475 and group 483, who were admitted to the adult medical, surgical, and cardiac intensive care units (ICU) in a university hospital. INTERVENTIONS: After the baseline year, a weaning management program was implemented throughout our institution. Primary endpoints were mortality, days on mechanical ventilation, ICU and hospital lengths of stay, hospital costs, and the percentage of patients requiring tracheostomy. MAIN RESULTS: The number of patients increased from 220 in the baseline year (year 0) to 247 in the first year (year 1), then to 267 in the second year (year 2). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score increased from 22.2 to 24.4 in year 1 (p =.006) and to 26.2 in year 2 (p <.0005). When year 0 was compared with year 1, mean days on mechanical ventilation decreased from 23.9 to 21.9 days (p =.608), hospital length of stay decreased from 37.5 to 31.6 days (p =.058), ICU length of stay decreased from 30.5 to 25.9 days (p =.133), and total cost per case decreased from $92,933 to $78,624 (p =.061). When year 0 was compared with year 2, mean days on mechanical ventilation decreased from 23.9 days to 17.5 days (p =.004), mean hospital length of stay decreased from 37.5 to 24.7 days, mean ICU length of stay decreased from 30.5 to 20.3 days, total cost per case decreased from $92,933 to $63,687, and percentage of patients requiring tracheotomy decreased from 61% to 41% (all p <.0005). There was also a reduction in the percentage of patients requiring more than one course of mechanical ventilation during the hospitalization from 33% to 26% (p =.039), a total cost savings of $3,440,787 and a decrease in mortality between all 3 yrs from 32% to 28% (p =.062). CONCLUSIONS: A multifaceted, multidisciplinary weaning management program can change the process of care used for weaning patients from mechanical ventilation throughout an acute care hospital and across multiple services. This change can lead to large reductions in the duration of mechanical ventilation, length of stay, and hospital costs, even at a time when patients are sicker.     

Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates

Background: Ventilator‐associated pneumonia (VAP) is a common complication of mechanical ventilation after endotracheal intubation. The role of chlorhexidine and tooth‐brushing has been considered as a clinical intervention to reduce infection rates, however, evidence to inform this needs appraising. Aim: This paper presents a critical review on the effect of chlorhexidine gluconate (CHX) and tooth‐brushing in decreasing rates of VAP in mechanically ventilated adult patients cared for in intensive care settings. Methods: A literature search was conducted using a number of bibliographic databases (n = 6). A number of parameters were used to exclude irrelevant papers. A total n = 17 papers were located and accessed, which were directly related to the field. Eight studies that met the criteria and addressed the study aims were reviewed. Findings: CHX was successful in reducing the rate of VAP and using a combination of CHX and colistine resulted in better oropharyngeal decontamination which reduced and delayed VAP. Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive care and had the potential to reduce nosocomial infections. Results of studies investigating the use of tooth‐brushing in reducing VAP incidence proved inconsistent, although all recommend tooth‐brushing as important in maintaining good oral hygiene. Conclusions: The use of chlorhexidine has been proven to be of some value in reducing VAP, although may be more effective when used with a solution which targets gram‐negative bacteria. Tooth‐brushing is recommended in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study design and inconsistency in results suggest that further research is required into the effects of tooth‐brushing.     

重症监护病房中选择性消化道脱污染对院内获得性肺炎的临床价值

目的探讨在重症监护病房（intonsive cane tmit,ICU）行选择性消化道脱污染（selective digestivedecontamination,SDD）的临床实用价值。方法选取2007年1月～2010年1月危重症患者376例,随机分为两组,对照组予常规口腔护理治疗,治疗组予选择性消化道脱污染治疗,比较两组患者病情疗效的参数。结果治疗组院内获得性肺炎发生率为18.4%、院内获得性肺炎发生时间（7.2±3.2）d、人工气道（气管插管/切开）保留天数（10.5±3.8）d、机械通气天数（8.4±3.1）d、入住ICU天数（14.7±4.8）d、病死率11.6%;对照组院内获得性肺炎发生率为30.1%、院内获得性肺炎发生时间（5.6±3.6）d、人工气道（气管插管/切开）保留天数（12.5±4.6）d、机械通气天数（10.2±4.2）d、入住ICU天数（17.2±6.2）d、病死率19.4%;两组比较差异均有统计学意义（P〈0.05）。结论在ICU内行选择性消化道脱污染可有效控制院内获得性肺炎,改善患者病情,减少住院天数,降低病死率。     

Prevention of nosocomial infection in critically ill patients by selective decontamination of the digestive tract

Objective: To evaluate the effect of a method of Selective Decontamination of the Digestive Tract (SDD) on colonization, nosocomial infection (NI), bacterial resistance, mortality and economic costs.Design: Randomized, double blind, placebo controlled study.Setting: Polyvalent intensive care unit (ICU) of a tertiary care hospital with 27 beds.Patients: 101 patients with >3 days of mechanical ventilation and >5 days of stay, without infection at the start of the study. 47 belonged to the Treated Group (TG) and 54 to the Placebo Group (PG).Interventions: The TG was given Cefotaxime i.v. (6 g/day) for the first four days and an association of Polymyxin E, Tobramycin and Amphothericin B at the oropharyngeal and gastrointestinal level throughout the whole stay.Results: In the TG, colonization by gram-negative agents at oropharyngeal, tracheal and gastrointestinal level fell significantly. There was a significant drop in the overall, respiratory and urinary NI (26% vs 63%,p<0.001; 15% vs 46%,p<0.001; 9% vs 31%,p<0.01). The overall mortality and NI related mortality was less in the TG (21% vs 44%,p<0.05; 2% vs 20%,p<0.01). The economic costs, mechanical ventilation time and length of stay were similar. The percentage of bacterial isolations resistant to Cefotaxime and Tobramycin was greater in the TG (38% vs 15% and 38% vs 9%,p<0.001).Conclusions: colonization by gram-negative bacilli, NI and the mortality related to it can be modified by SDD. Continuous bacteriological surveillance is necessary.     

自主呼吸试验在撤机中的应用

目的 对应用自主呼吸试验(SBT)撤机方式与逐渐降低机械通气支持水平撤机方式成功拔管的患者进行比较,以寻找最佳撤机方式.方法 选择57例机械通气患者,病情稳定后通过撤机试验前评估,然后准备撤机.采用前后对照的方法将患者分为两组,2004年6月-2005年12月的21例患者作为对照组,采用逐渐降低机械通气支持水平的撤机方式拔管;2006年1月-2007年3月的36例患者作用为试验组,采用SBT的撤机方式拔管.分别观察两组患者的机械通气时间、住重症监护病房(ICU)时间、呼吸机相关性肺炎(VAP)发生率、48 h内再插管率、ICU病死率.结果 试验组与对照组的机械通气时间分别为(59.45±37.1)h和(111.4±59.8)h(P=0.001),住ICU时间分别为(8.0±5.5)d和(15.3±14.3)d(P=0.034),VAP发生率分别为16.7%和38.0%(P=0.070),48 h内再插管率分别为19.4%和5.0%(P=0.253),ICU病死率分别为25.0%和24.0%(P=0.920).结论 SBT的撤机方式比逐渐降低机械通气支持水平的撤机方式具有机械通气时间和住ICU时间短的优点,而两组VAP发生率、48 h内再插管率、ICU病死率基本相同.     

Prevention of ventilator-associated pneumonia,mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units

Introduction  

Given the high morbidity and mortality attributable to ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, prevention plays a key role in the management of patients undergoing mechanical ventilation. One of the candidate preventive interventions is the selective decontamination of the digestive or respiratory tract (SDRD) by topical antiseptic or antimicrobial agents. We performed a meta-analysis to investigate the effect of topical digestive or respiratory tract decontamination with antiseptics or antibiotics in the prevention of VAP, of mortality and of all ICU-acquired infections in mechanically ventilated ICU patients.     

机械通气老年患者院内气管支气管炎危险因素分析

目的 探讨机械通气老年患者并发院内气管支气管炎（NTB）的危险因素，为制定院内感染防治措施提供流行病学资料和科学依据。方法 应用前瞻性队列研究方法，观察2002年10月-2004年7月收治上海复旦大学附属中山医院外科重症监护室（SICU）内的老年机械通气患者的临床资料，进行单因素和多因素Logistic回归分析。结果 符合标准的66例SICU内机械通气老年患者有35例发生NTB（发生率为53．03％）。NTB组和非NTB组在低白蛋白血症、鼻饲情况、机械通气时间、急性生理学与慢性健康状况评分Ⅱ（APACHEⅡ）、抗生紊使用种数以及住SICU时间方面差异均有显著性（P〈0．05或P〈0．01）。单因素分析显示：鼻饲、低白蛋白血症、机械通气时间〉4d、住SICU时间〉9d、抗生素使用种数增加以及APACHEⅡ评分〉9分是NTB发生的重要危险因素;Logistic多因素回归分析显示：鼻饲、机械通气时间〉4d、抗生素使用种数〉2种是NTB的独立发病危险因素。结论 SICU内机械通气老年患者NTB的发生率较高，是影响患者预后的重要因素之一。机械通气时间延长、ICU内住院时间延长、低白蛋白血症、高APACHEⅡ评分、大量使用抗生素等是NTB发生的重要危险因素。     

The impact of ventilator-associated pneumonia on the Canadian health care system

INTRODUCTION: Ventilator-associated pneumonia (VAP) is a cause of morbidity and mortality in critically ill patients. It is associated with increased health care costs and duration of mechanical ventilation. Using published data and information from public health care providers, we sought to determine the impact of VAP on the Canadian health care system. METHODS: Ventilator-associated pneumonia incidence, attributable mortality, and intensive care unit (ICU) utilization/resource data were obtained through Canadian published and institutional data. Ontario case cost methodology was used for the cost of a critical care bed which is CAN dollars 2396 per day, excluding treatment costs. Antibiotic acquisition costs for Ontario were used. Physician reimbursement rates were obtained from the provincial ministries of health. Ventilator-associated pneumonia data, ICU resource data, and costs were combined to determine the impact of VAP. RESULTS: For the Canadian health care system; ICU utilization is 217 episodes per 100000 population and 1150 days of mechanical ventilation per 100000. The incidence of VAP is 10.6 cases per 1000 ventilator days (95% CI, 5.1-16.1). Ventilator-associated pneumonia increases ICU length of stay 4.3 days (95% CI, 1.5-7.0 days) per episode. The attributable mortality of VAP is 5.8% (95% CI, -2.4 to 14). The number of cases of VAP is estimated to be approximately 4000 cases per year (95% CI, 1900-6100). This results in 230 deaths per year with the lower and upper confidence intervals ranging from 0 to 580. Ventilator-associated pneumonia accounts for approximately 17000 ICU days per year or around 2% of all ICU days in Canada. The cost to the health care system is CAN dollars 46 million (possible range, dollars 10 million to 82 million) per year. CONCLUSION: The impact of VAP on the Canadian health care system is considerable. Eradication of this preventable nosocomial infection would save lives and conserve scarce health care resources.     

早期护理干预在机械通气患者中的应用及效果观察

目的:探讨早期护理干预在机械通气患者中的应用及临床效果。方法:将2006年1月～2007年12月收治的342例机械通气患者作为对照组,给予常规护理;将2008年1月～2009年12月收治的342例机械通气患者作为护理组,在常规护理基础上给予护理干预。比较两组送检标本细菌检出阳性率、呼吸机相关肺炎(VAP)发生率、机械通气时间及ICU住院时间。结果:护理组送检标本细菌培养阳性率为37%,对照组阳性率为45%;护理组VAP发生率低于对照组(P<0.05),机械通气时间及ICU住院时间少于对照组(P<0.05)。结论:早期护理干预可以降低机械通气患者VAP发生率,缩短机械通气时间及ICU住院时间,促进患者康复。