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ORIGINAL ARTICLE
Year : 2020  |  Volume : 38  |  Issue : 3  |  Page : 289-292
 

Efficacy of chlorhexidine wipes on colonization of Pseudomonas aeruginosa and Staphylococcus aureus in both ventilator and nonventilator patients in pediatric intensive care unit


1 Consultant Pedodontist, Bengaluru, Karnataka, India
2 Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India

Date of Submission09-Jun-2020
Date of Decision11-Aug-2020
Date of Acceptance09-Sep-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Dr. P N Navya
R T Nagar, Bengaluru - 560 032, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_268_20

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   Abstract 


Objective: In this coronavirus disease 2019 pandemic, pediatric children who are admitted in the intensive care unit (ICU) are more susceptible to ventilator-associated pneumonia. Ventilator-associated pneumonia is the second-most common hospital-acquired infection in pediatric ICU. Oral hygiene maintenance is a challenge here. To maintain oral hygiene and to prevent colonization of microorganisms such as Pseudomonas aeruginosa and Staphylococcus aureus which cause ventilator-associated pneumonia, a study was conducted, which aimed at finding the efficacy of chlorhexidine (CHX) wipes (as an oral hygiene aid) on colonization of these organisms in pediatric ICU. Methods and Methodology: The study was conducted among twenty children (8 in ventilation and 12 without ventilation) in the age range of 6–14 years admitted in the pediatric ICU. Swab sample was taken on the 1st day from both groups. Culturing of swab sample was done for colonization of microorganisms. CHX gluconate with a concentration of 0.2% was used as wipes. Swab sample was collected at the end of the 2nd day. Culturing of swab sample was done for colonization of microorganisms. Statistical analysis was done. Results: A statistically significant difference (P ≤ 0.04) was seen in the ventilator group with a mean of 0.75 ± 13.241 in the reduction of S. aureus count. P. aeruginosa growth was not seen in either of the groups before or after the use of CHX wipe. Conclusions: Standard oral hygiene practice has the potential to contribute to improved oral and general health of children in pediatric ICU. CHX wipes significantly reduced S. aureus count in ventilator patients. Hence, it could be used as an effective antimicrobial agent in pediatric ICU.


Keywords: Chlorhexidine wipes, oral hygiene aid, Pseudomonas aeruginosa, Staphylococcus aureus, ventilator-associated pneumonia


How to cite this article:
Navya P N, Dhananjaya G, Chandra P. Efficacy of chlorhexidine wipes on colonization of Pseudomonas aeruginosa and Staphylococcus aureus in both ventilator and nonventilator patients in pediatric intensive care unit. J Indian Soc Pedod Prev Dent 2020;38:289-92

How to cite this URL:
Navya P N, Dhananjaya G, Chandra P. Efficacy of chlorhexidine wipes on colonization of Pseudomonas aeruginosa and Staphylococcus aureus in both ventilator and nonventilator patients in pediatric intensive care unit. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2020 Oct 22];38:289-92. Available from: https://www.jisppd.com/text.asp?2020/38/3/289/296630





   Introduction Top


Coronavirus disease 2019 (COVID-19) can be a life-threatening infection, especially in the old and immune compromised patients, and is a significant cause of morbidity and mortality in patients of all ages. These patients are in the intensive care unit (ICU) or on intubation, which can in turn lead to ventilator-associated pneumonia. Ventilator-associated pneumonia is a type of lung infection that critically affects people who are on mechanical ventilation in hospitals. It is the second-most common hospital-acquired infection and the main cause is due to the improper oral hygiene maintenance.

Studies done at pediatric ICU report an incidence of ventilator-associated pneumonia between 6.1% and 15.1%.[1],[2] Another cross-sectional study found a prevalence of 11.9%.[3] Available information suggests that nosocomial infections are increasing day by day. The key in the rise is due to colonization of the upper respiratory tract (oropharynx and trachea) with potentially pathogenic microorganisms, such as Pseudomonas aeruginosa, Staphylococcus aureus, and Enterobatericeae. Poor oral hygiene in mechanically ventilated patients can lead to bacterial colonization in the oropharynx. There is a strong correlation between the bacteria colonizing in the oropharynx and those causing ventilator-associated pneumonia.[4]

Poor oral hygiene is one among the most common risk factors of pneumonia in nursing homes.[5] Patients in ICU settings are predisposed to develop colonies of more virulent pathogens than found in the normal oral environment of healthy people. Peter D'Adamo has said antibiotics cut off immune response, as antibiotics take over body's responsibility for fighting an infection. And also, low priority is given to oral care in nursing education programs. This may partially account for the continuing low priority of oral care in the ICU. A study was done to evaluate the nurses' opinion and practice about oral care in patients under mechanical ventilation.[6] They found that nurses did not consider oral care in patients as a high priority.

Dental plaque is an important site for the growth of pathogenic bacteria as they provide a site for microorganisms that are responsible for the development of ventilator-associated pneumonia among pediatric and neonatal ICU patients. Hence, oral hygiene maintenance is a major concern in children who are admitted in the ICU.

Chlorhexidine (CHX) gluconate is a broad-spectrum bactericidal solution. Intubated patients who received oral hygiene care, twice daily with 0.12% CHX gluconate, had a lower incidence of nosocomial pneumonia. A Cochrane review has stated that the CHX mouthwash is associated with a 40% reduction in developing ventilator-associated pneumonia in adult critically ill patients.[7],[8] There is not much research seen on pediatric patients of ICU. Hence, this study was conducted to find out the efficacy of CHX wipes on colonization of P. aeruginosa and S. aureus in both ventilator and nonventilator patients in pediatric ICU.


   Methods and Methodology Top


An interventional study was conducted for a period of 2 months. A total of twenty children, 8 on ventilator and 12 nonventilator patients who were admitted in the pediatric ICU in our teaching hospital, were recruited for the study. The age of children ranged between 6 and 14 years. Patients who were transferred from another ICU or re-admission to the ICU were not included in the study.

An informed consent was obtained from all patients' parents. Oral hygiene examination was done by a single dentist for both groups of patients. Swab sample was collected, and culturing was done for colonization of P. aeruginosa and S. aureus in both the ventilator and nonventilator groups [Figure 1]. Oral hygiene was monitored for all patients, and CHX wipes were administered for 2 days with an interval of 12 h. Swab sample was collected at the end of the 2nd day from both groups for culturing.
Figure 1: Swab sample collection

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Chlorhexidine wipe preparation

The CHX gluconate mouth wash concentration of 0.2% (Clohex Plus from Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India) was used. A sponge brush (standard size gauze 1” × 1“) was soaked in 5 mL of 0.2% CHX gluconate solution and used as a wipe. The buccal, gingival, and palatal mucosae were wiped twice with the sponge brush from the posterior to the anterior region for 2 days with a 12-h interval [Figure 2].
Figure 2: Buccal, gingival, and palatal mucosae wiped with chlorhexidine wipes

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Culture

Culturing of the swab sample was done for colonization of microorganisms by quantifying colonies using standard culture technique. Mannitol salt agar and MacConkey agar were used for culturing of P. aeruginosa and S. aureus, respectively [Figure 3].
Figure 3: Cultured samples in mannitol salt agar and MacConkey agar

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Statistical analysis

Unpaired t-test was done to compare the means in the two groups after the use of CHX. Paired t-test was done within the groups to measure the mean scores before and after the use of CHX.


   Results Top


A statistically significant difference (P ≤ 0.04) was seen in the ventilator group with a mean of 0.75 ± 13.241 in the reduction of S. aureus count [Table 1]. However, no statistically significant difference was observed in the nonventilator group after the use of CHX wipes. P. aeruginosa growth was not seen in either of the groups before or after the use of CHX wipe.
Table 1: Mean Staphylococcus aureus count among patients on ventilators and nonventilator patients in the intensive care unit

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   Discussion Top


The COVID-19 pandemic has spread widely, affecting all age group. About 2% of the cases are children below 18 years of age. When children are admitted in the ICU and on ventilator, their oral hygiene is neglected, which in turn deteriorates the overall health of the individual. Poor oral hygiene is one among the most common risk factors of pneumonia in pediatric ICU.[5] Colonization in the oral cavity, followed by aspiration of bacteria-laden oropharyngeal secretions into the lower respiratory tract, remains the most common path of infection for typical bacterial pneumonia.[9]

Oral hygiene in the ICU needs to be a must-performed procedure, which ensures that the patient mouth is cared. The lack of specific designated personnel to perform oral care, lack of adequate training of nursing staff, resident noncompliance with care, and choice of oral care itself lead to a major setback.[10],[11]

CHX gluconate oral rinse provides antimicrobial activity during oral rinsing. Microbiological sampling of plaque followed by the use of CHX gluconate oral rinse has shown a general reduction in the counts of assayed bacteria, both aerobic and anaerobic. A study was conducted in geriatric patients, which used sponge brush soaked in CHX gluconate for wiping oral mucosa for 4 months, result of the study showed CHX gluconate significantly decreased opportunistic infections in the oropharynx region.[12]

A study done to determine the effect of oral decontamination with CHX (CHX, 2%) or CHX/colistin (CHX/COL, 2%/2%) reported that topical oral decontamination with CHX or CHX/COL reduced the incidence of ventilator-associated pneumonia.[13]

The result of the present study is in par with the result of the study which was done to determine 0.12% CHX gluconate application to reduce oral colonization by pathogens in 175 intubated patients in a trauma ICU. They concluded that decontamination of the oral cavity with CHX did not reduce the total number of potential respiratory pathogens, but it did reduce the number of S. aureus in dental plaque of trauma intensive care patients.[14]

CHX gluconate use in the early postintubation period mitigated or delayed the development of ventilator-associated pneumonia.[15] Hence, it is advised to use CHX as an effective antibacterial agent in the prevention of ventilator-associated pneumonia. The study limitations were most of the children who were admitted in the ICU were discharged within 72hours from the ICU to the normal ward; the minimum incubation period for P. aeruginosa is 48 h, which was the major reason for the unnoticed effect of the growth of the organism; and, it was a pilot study done in a small group of sample.


   Conclusions Top


The study emphasizes on an interdisciplinary approach in the management of oral hygiene and its importance in patients in the pediatric ICU. Standard oral hygiene practice has the potential to improve the oral and general health of the children. CHX wipes significantly reduced S. aureus count in ventilated patients. Hence, in this pandemic situation, it can be considered an effective agent to improve oral hygiene in pediatric ICU.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Urrea M, Pons M, Serra M, Latorre C, Palomeque A. Prospective incidence study of nosocomial infections in a pediatric intensive care unit. Pediatr Infect Dis J 2003;22:490-3.  Back to cited text no. 1
    
2.
Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. National nosocomial infections surveillance system. Crit Care Med 1999;27:887-92.  Back to cited text no. 2
    
3.
Grohskopf LA, Sinkowitz-Cochran RL, Garrett DO, Sohn AH, Levine GL, Siegel JD, et al. A national point-prevalence survey of pediatric intensive care unit-acquired infections in the United States. J Pediatr 2002;140:432-8.  Back to cited text no. 3
    
4.
Garrouste-Orgeas M, Chevret S, Arlet G, Marie O, Rouveau M, Popoff N, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med 1997;156:1647-55.  Back to cited text no. 4
    
5.
Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis 2005;40:1-6.  Back to cited text no. 5
    
6.
Adib-Hajbaghery M, Safa A. Nurses' evaluation of their use and mastery in health assessment skills: Selected Iran's hospitals. Nurs Midwifery Stud 2013;2:39-43.  Back to cited text no. 6
    
7.
Corbet EF, Tam JO, Zee KY, Wong MC, Lo EC, Mombelli AW, et al. Therapeutic effects of supervised chlorhexidine mouthrinses on untreated gingivitis. Oral Dis 1997;3:9-18.  Back to cited text no. 7
    
8.
Grenier D. Effect of chlorhexidine on the adherence properties of Porphyromonas gingivalis. J Clin Periodontol 1996;23:140-2.  Back to cited text no. 8
    
9.
Scannapieco FA, Genco RJ. Association of periodontal infections with atherosclerotic and pulmonary diseases. J Periodontal Res 1999;34:340-5.  Back to cited text no. 9
    
10.
Coleman P. Resistive behaviors of elderly nursing home residents during oral care. Geriatr Nurs 2005;6:349-50.  Back to cited text no. 10
    
11.
Hardy DL, Darby ML, Leinbach RM, Welliver MR. Self-report of oral health services provided by nurses' aides in nursing homes. J Dent Hyg 1995;69:75-82.  Back to cited text no. 11
    
12.
Tashiro K, Katoh T, Yoshinari N, Hirai K, Andoh N, Makii K, et al. The short-term effects of various oral care methods in dependent elderly: Comparison between toothbrushing, tongue cleaning with sponge brush and wiping on oral mucous membrane by chlorhexidine. Gerodontology 2012;29:e870-82.  Back to cited text no. 12
    
13.
Koeman M, van der Ven AJ, Hak E, Joore HC, Kaasjager K, de Smet AG, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006;173:1348-55.  Back to cited text no. 13
    
14.
Scannapieco FA, Yu J, Raghavendran K, Vacanti A, Owens SI, Wood K, et al. A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Crit Care 2009;13:R117.  Back to cited text no. 14
    
15.
Grap MJ, Munro CL, Elswick RK Jr, Sessler CN, Ward KR. Duration of action of a single, early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: A pilot study. Heart Lung 2004;33:83-91.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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