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

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):3854-62.

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):665-71. 2. Kozlow JH, et al., Crit Care Med. 2003;31(7):1930-7

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)

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):3854-62.

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

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: http://dictionary.reference.com/browse/Biofilm

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.

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.

http://www. erc. montana http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

How They Form http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Structure-Function/default.htm

Biofilm forming over 12 hours Formation of Biofilm Biofilm forming over 12 hours http://www.tumoutou.net/702_05123/it_jamilah.htm

Plaque as a Biofilm http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

Biofilm Dispersing http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Structure-Function/default.htm

Biofilm Entering into Alveoli http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

Biofilm Growing and Strengthening http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

Biofilm Calcifies http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

How Do We Combat Biofilms?

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):32232-87 (available atwww.fda.gov/cder/otcmonographs/Oral_Health_Care/gingivitis_&_plaque_PR_20030529.pdf).2

Oral Debridement Oral Health Care Drug Products for Over-the-Counter HumanUse;Tentative Final Monograph;Federal Register,53(17):2436-61 (available at www.fda.gov/cder/otcmonographs/Oral_Health_Care/oral_health_care_TF_PR_19880127.pdf).

With q12º brushing and q2º-q4º swabbing, we should stop the development of biofilms. http://www.tumoutou.net/702_05123/it_jamilah.htm

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.

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.

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.

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.

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