2. gain entrance to the lungs.”
ASPIRATION PNEUMONITIS AND ASPIRATION PNEUMONIA Paul E. Marik, M.B., B.CH N Engl J Med, Vol. 344, No. 9 ·March 1, 2001
“Aspiration pneumonia develops after the inhalation of colonized oropharyngeal material. Aspiration of colonized secretions from the oropharynx is the primary mechanism by which bacteria
gain entrance to the lungs.”
Marik PE, N Engl J Med, Vol. 344, No. 9 ·March 1, 2001

3. Defining HAP and HCAP Hospital-Acquired Pneumonia (HAP)
Not on Vent and Positive Respiratory culture after
2 days from admission.
Health Care-Associated Pneumonia (HCAP)
1. Transferred from
another facility.
2. Long-term dialysis.
3. Prior Hospitalization within 30 days who do not meet VAP definition.
Positive respiratory culture within 2 days of admission and any of the following:
Kollef MH, et al., Chest. Dec 2005;128(6):

4. Patients At Risk
Those suffering from neurologic dysphagia, stroke, COPD, malignancy, renal disease, dementia, liver disease, enteral feeding, suppressed immune systems, emergency room admission and more.1,2
1. Marik PE, N Engl J Med. 2001;344(9): Kozlow JH, et al., Crit Care Med. 2003;31(7):1930-7

5. Predictors of Aspiration Pneumonia: How Important Is Dysphagia?* Susan E. Langmore, PhD Dysphagia 13:69–81 (1998)
“Aspiration pneumonia is a major problem for the elderly, leading to hospitalization, costly care, and at times death. It accounts for anywhere from 13% to 48% of all infections in nursing home residents and is the second most common type of nosocomial infection in hospitalized patients, after urinary tract infections.”
Susan E. Langmore, PhD Dysphagia 13:69–81 (1998)

6. High Mortality, Longer Stays, Increased Costs
HAP
18.8%
15.2 days
$65,292
VAP
29.3%
23 days
$150,841
HCAP
19.8%
8.8 days
$27,647
Mortality
Length
of Stay
Mean Hospital Charges
Kollef MH, et al., Chest. Dec 2005;128(6):

7. Biofilm as a Risk Factor for Pneumonia
Staphylococcus aureus biofilm on an indwelling catheter.

8. Biofilm Defined
A thin, usually resistant layer of microorganisms (as bacteria) that form on and coat various surfaces.
Biofilm. (n.d.). Merriam-Webster's Medical Dictionary. Retrieved July 03, 2007, from Dictionary.com website:

9. Biofilms and Infectious Diseases
Biofilms have been found to be involved
in a wide variety of microbial infections
in the body– by one estimate, 80% of
all infections.
Immunology of Biofilms. Immunology and Immunotherapy Program, Center for Integrative Biology and Infectious Diseases, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 2004.

10. Biofilms and Infectious Diseases
Infectious processes in which biofilms have been implicated include common problems such as urinary tract infections, catheter infections, middle-ear infections, formation of dental plaque and gingivitis.
Immunology of Biofilms. Immunology and Immunotherapy Program, Center for Integrative Biology and Infectious Diseases, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 2004.

11. http://www. erc. montana

12. How They Form

13. Biofilm forming over 12 hours
Formation of Biofilm
Biofilm forming over 12 hours

14. Plaque as a Biofilm

15. Biofilm Dispersing

16. Biofilm Entering into Alveoli

17. Biofilm Growing and Strengthening

18. Biofilm Calcifies

19. How Do We Combat Biofilms?

20. Mechanical Cleansing with Antiseptic Agent
Oral Health Care Drug Products for Over-the-Counter Human Use;Antigingivitis / Antiplaque Drug Products;Establishment of a Monograph;Federal Register,68(103): (available atwww.fda.gov/cder/otcmonographs/Oral_Health_Care/gingivitis_&_plaque_PR_ pdf).2

21. Oral Debridement
Oral Health Care Drug Products for Over-the-Counter HumanUse;Tentative Final Monograph;Federal Register,53(17): (available at

22. With q12º brushing and q2º-q4º swabbing, we should stop the development of biofilms.

23. Recap
Mechanical Cleansing with an oral antiseptic helps to kill and remove biofilms.
Oral Debridement helps lift and remove inactive biofilms that are left behind.

24. Listen to the Experts
CDC Guidelines for Preventing Health Care-Associated Pneumonia
“...Develop and implement a comprehensive oral-hygiene program (that might include use of an antiseptic agent) for patients in acute-care settings or residents in long-term--care facilities who are at risk for health-care--associated pneumonia (II).”*,1
*In addition to other interventions.
1.Tablan OC, et al., “Guidelines for preventing health-care--associated pneumonia, 2003,” Recommendations of CDC and HICPAC, 2003.

25. ACCN Practice Alert Expected Practice:
Develop and implement a comprehensive oral hygiene program for patients in critical care and acute care settings who are at high risk for healthcare-associated pneumonia.
Brush teeth, gums and tongue at least twice a day using a soft pediatric or adult toothbrush.
In addition to brushing, provide oral moisturizing to oral mucosa and lips every
2 to 4 hours.
AACN Practice Alert - Oral Care in the Critically Ill - Aug 2006.

26. Oral Care Reduces Pneumonia in Older Patients in Nursing Homes Yoneyama et al. J Am Ger Soc 50:2002
11 nursing homes in Japan.
417 patients randomly assigned to “oral care” or “no oral care.”
Oral care provided by nurses or caregivers.
Pneumonia, febrile days, death from pneumonia decreased significantly in patients with oral care.
Yoneyama et al. J Am Ger Soc 50:2002.

27. Oral Care for Everyone

28. Evidence Based Protocols
Assessment
Cleaning
Debriding
Suctioning
Moisturizing

29. Support Educational Website Protocols Implementation plan
Protocol support tool
Cost Justification tool
Performance Improvement plan

30. Begin With The End In Mind

31. Protocol–Customize to Your Facility

32. Performance Improvement Plan

33. Clinical Feedback Forms

34. Protocol Surveillance Tool

35. Implementation Plan