The role of selective decontamination of the digestive tract in acute stroke. Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. Improving oral health in institutionalised elderly people by educating caregivers: a randomised controlled trial.
following a stroke, morbidity and mortality is high, with aspiration pneumonia being a common complication.
                to determine the levels of colonisation by and isolation of aerobic Gram-negative bacteria (AGNB) in acute stroke patients and determine the effect of selective decontamination of the digestive tract (SDD) on oral flora and whether it reduces both morbidity and mortality after an acute stroke.
                a prospective, randomised, placebo-controlled double blind trial.
                acute stroke assessment units of three hospitals in the northwest of England.
                203 patients admitted to hospital following a first acute stroke.
                participants were randomised to SDD oral gel or placebo. Swallow was assessed on admission to hospital, and oral swabs were obtained thrice weekly. Demographic and clinical data were recorded.
                203 patients (106 males and 97 females) participated, of whom 20 died during their hospitalisation, 19 withdrew and full follow-up was obtained for the remaining 164. A total of 122 AGNB were isolated in 105 samples from 48 patients. Abnormal swallow on admission was found in 58 patients (29%). A total of 34 patients carried a single gram-negative micro-organism that was present on one or more occasions. More than one AGNB was carried in 14 patients, and organisms were significantly more likely to be isolated from the placebo group than the active group during weeks 2 and 3 of treatment (P = 0.034, chi-squared). Seven patients in the placebo group and one in the treatment group developed pneumonia (P = 0.029, Fisher's exact test).
                high carriage of and colonisation by AGNB was found within this study, which was reduced by the addition of SDD. Although SDD reduced the presence of both organisms and documented episodes of pneumonia, mortality remained unchanged. Ventilator-associated pneumonia (VAP) is a preventable secondary consequence of intubation and mechanical ventilation. VAP is pneumonia that develops in an intubated patient after 48 hours or more of mechanical ventilator support. Mechanically ventilated patients in neurologic and other intensive care units (ICUs) are at an increased risk of VAP due to factors such as decreased level of consciousness; dry, open mouth; and microaspiration of secretions. VAP can be prevented by initiating interventions from the Institute of Healthcare Improvement's VAP bundle, including (a) elevating the head of the bed of ventilated patients to 30 degrees, (b) preventing venous thromboembolism through use of sequential compression devices or anticoagulation, (c) administering gastric acid histamine2 blockers, (d) practicing good hand hygiene, (e) initiating early mobilization, and (f) performing daily sedation interruption at 10 am to evaluate neurologic status. The one intervention not included in the IHI bundle is oral hygiene. The purpose of this project is to support the premise that oral care, including timed toothbrushing, combined with the VAP bundle can mitigate and prevent the occurrence of VAP. Our project specifically addressed timed oral care of mechanically ventilated patients on a 24-bed stroke, neurologic, and medical ICU. Patients were randomized into a control group that performed usual oral care or an intervention group that brushed teeth every 8 hours. The results were immediate and startling, as the VAP rate dropped to zero within a week of beginning the every-8-hours toothbrushing regimen in the intervention group. The study was so successful that the control group was dropped after 6 months, and all intubated patients' teeth were brushed every 8 hours, maintaining the zero rate until the end of the study. This cluster-randomised controlled trial assessed whether oral health care education (OHCE) for nursing home caregivers would achieve improvements in clients' oral health.
                Twenty-two nursing homes were randomly allocated to intervention or control group. Clients were examined at baseline and at follow-up visits 1- and 6-months after caregivers received OHCE. Main outcome measures were denture plaque, denture-induced stomatitis, dental plaque and gingivitis. Differences in group means/medians were compared with adjustment for cluster randomisation.
                Clients' baseline oral health was poor. After OHCE, the intervention group's oral health scores improved significantly. Reductions in denture plaque scores (0-4 scale) exceeded those of the control group by 1.15 (95%CI=0.83, 1.47) at 1 month and by 1.47 (95%CI=1.13, 1.80) at 6 months. Denture-induced stomatitis prevalence reduced significantly over 6 months compared to the control group (P<0.0001). Group differences in favour of the intervention group were 0.41 (95%CI=0.18, 0.65) at 1 month and 0.34 (95%CI=0.14, 0.53) at 6 months for dental plaque (0-3 scale), and 0.17 (95%CI= -0.01, 0.35) at 1 month and 0.28 (95%CI 0.15, 0.42) at 6 months for gingivitis (0-2 scale). Key differences remained significant after adjustment for clustering effects. The provider's costs would currently be approximately pounds 6700 per year to deliver the intervention to a Health Authority with 100 homes.
                Although final levels of residents' oral health were still short of ideal, this study clearly shows that, for a modest cost, OHCE can improve caregivers' knowledge, attitudes and oral health care performance for elderly, functionally dependent clients.
Based on two trials involving a small number of stroke survivors, OHC interventions can improve staff knowledge and attitudes, the cleanliness of patients' dentures and reduce the incidence of pneumonia. Improvements in the cleanliness of patients teeth were not observed. Further evidence relating to staff-led oral care interventions is severely lacking.