在醫院中刷牙可減少感染和死亡

Elena Riboldi /  2024/01/12  / Medscape 醫療新聞

每天刷牙可降低醫院獲得性肺炎 (HAP) 的發生率，特別是接受機械通氣的患者。這種做法還可以降低重症監護病房 (ICU) 死亡率、縮短 ICU 入院時間以及縮短呼吸器依賴時間。這些是發表在《美國醫學會內科學》雜誌上的一項薈萃分析的結果。醫院政策必須重新評估口腔衛生的重要性，甚至在注意力集中在其他地方的情況下也是如此。

口腔微生物群和肺部

HAP 很大程度上是由口腔中存在的微生物的吸入引起的。事實上，口腔微生物群估計包含 700 種細菌、真菌、病毒和原生動物。眾所周知，口腔健康與肺炎的發生之間存在聯繫，嚴格的口腔衛生是預防 HAP 的建議的一部分。但確保良好衛生的方法尚未確定。使用氯己定（註）漱口水存在爭議，因為沒有證據顯示它可以預防肺炎，而且一些研究顯示氯己定與較高的死亡率之間存在關聯。

在減少口腔微生物群方面，刷牙可能比抗菌劑更有效，因為機械作用會破壞牙菌斑和其他生物膜。然而，指引很少關注刷牙作為預防醫院獲得性感染的措施，這意味著每家醫院都有自己的做法。

數據顯示什麼

麻薩諸塞州劍橋市哈佛大學人口醫學系的 Selina Ehrenzeller 醫學博士和 Michael Klompas 醫學博士、公共衛生碩士進行了系統性的文獻分析，以確定每天刷牙會影響以下人群患 HAP 風險的隨機臨床研究：成人醫院住院病人。十五篇研究符合納入標準並用於薈萃分析。有效人群規模為 2,786 名患者。

每天刷牙可使 HAP 風險降低 33%（相對風險 [RR]，0.67），使 ICU 死亡率風險降低 29%（RR，0.81）。接受侵入性機械通氣的患者肺炎發生率顯著降低（RR，0.68），但未接受侵入性機械通氣的患者則不然。 ICU 患者刷牙與較少的機械通氣天數（平均差，-1.24 天）和較短的 ICU 住院時間（平均差，-1.78 天）有關。每天刷牙兩次與更頻繁的刷牙間隔有相似的效果估計。不同 ICU 科室的住院時間以及與每日刷牙相關的抗生素的使用沒有差異。

專家意見

耶魯大學紐黑文分校傳染病助理教授魯帕克·達塔(Rupak Datta) 博士寫道：「這項研究對感染預防做出了令人興奮的貢獻，並強化了常規刷牙是機械通氣患者護理標準的重要組成部分這一觀念。」康乃狄克州醫院環境抗菌素抗藥性專家在對該研究的評論中。 Datta 表示，這種做法在預防非通氣 HAP 方面的重要性仍存在不確定性，因為研究人員只能確定兩項針對符合納入標準的非通氣患者的研究。還需要其他研究來幫助標準化入院患者的一般刷牙方式。達塔總結道：「隨著有關 HAP 的文獻不斷發展，口腔衛生可能在預防和控制醫院獲得性感染方面發揮著不可或缺的作用，類似於洗手」。

本文翻譯自 Univadis Italy，該機構是 Medscape Professional Network 的一部分。

引用此內容：醫院刷牙可減少感染和死亡 – Medscape – 2024 年 1 月 12 日。

註：氯己定口腔沖洗劑 (chlorhexidine-based mouthwash) 它是一種與刷牙和使用牙線一起用作口腔沖洗劑來治療牙齦炎的藥物。作為一種強效抗菌藥物，葡萄糖酸氯己定漱口水可以減少口腔中的細菌數量，從而減少牙齦問題，例如腫脹、出血和發紅。

如果您正在接受牙齦疾病治療或進行某些牙科手術，您的牙科專家可能會開出一種具有抗菌特性的處方漱口水，稱為氯己定漱口水。它是一種與刷牙和使用牙線一起用作口腔沖洗劑來治療牙齦炎的藥物。作為一種強效抗菌藥物，葡萄糖酸氯己定漱口水可以減少口腔中的細菌數量，從而減少牙齦問題，例如腫脹、出血和發紅。

Toothbrushing in Hospital Reduces Infections and Death

Elena Riboldi / January 12, 2024 / Medscape Medical New

Daily toothbrushing is associated with a reduced incidence of hospital-acquired pneumonia (HAP), especially in patients on mechanical ventilation. This practice also is associated with lower intensive care unit (ICU) mortality, shorter ICU admissions, and shorter ventilator dependency. These are the findings of a meta-analysis published in JAMA Internal Medicine. Hospital policies must reassess the importance of oral hygiene even, or perhaps especially, in situations in which attention is focused elsewhere.

Oral Microbiota and Lungs

HAP largely results from the aspiration of microorganisms present in the oral cavity. In fact, the oral microbiota comprises an estimated 700 species of bacteria, fungi, viruses, and protozoa. There is a known link between oral health and the development of pneumonia, and rigorous oral hygiene is part of the recommendations for preventing HAP. But the methods that should be used for ensuring good hygiene haven’t been determined. The use of chlorhexidine-based mouthwash is debated because there is no evidence that it prevents pneumonia and because some studies have suggested a link between chlorhexidine and higher mortality rates.

Toothbrushing is potentially more effective than antiseptic at reducing the oral microbiota because the mechanical action breaks up plaque and other biofilms. Yet, guidelines have focused very little on brushing as a measure for preventing hospital-acquired infections, meaning that every hospital has its own way of doing things.

What Data Show

Selina Ehrenzeller, MD, and Michael Klompas, MD, MPH, of the Department of Population Medicine at Harvard University in Cambridge, Massachusetts, conducted a systematic literature analysis to identify randomized clinical studies in which daily toothbrushing was shown to affect the risk for HAP in adult hospital inpatients. Fifteen studies met the inclusion criteria and were used for the meta-analysis. The effective population size was 2786 patients.

Daily toothbrushing was associated with a 33% lower risk for HAP (relative risk [RR], 0.67) and a 29% lower risk for ICU mortality (RR, 0.81). Reduction in pneumonia incidence was significant for patients receiving invasive mechanical ventilation (RR, 0.68) but not for patients who were not receiving invasive mechanical ventilation. Toothbrushing for patients in the ICU was associated with fewer days of mechanical ventilation (mean difference, −1.24 days) and a shorter ICU length of stay (mean difference, −1.78 days). Brushing twice a day vs more frequent intervals was associated with similar effect estimates. No differences were seen in duration of stay in various ICU subdepartments and in the use of antibiotics that were linked to daily toothbrushing.

Expert Opinion

“This study represents an exciting contribution to infection prevention and reinforces the notion that routine toothbrushing is an essential component of standard of care in ventilated patients,” wrote Rupak Datta, MD, PhD, assistant professor of infectious diseases at Yale University in New Haven, Connecticut, and specialist in antimicrobial resistance in hospital settings, in a commentary on the study. According to Datta, there is still uncertainty regarding the importance of this practice in preventing nonventilator-HAP, as the investigators could only identify two studies with nonventilated patients that met inclusion criteria. Other studies will be needed to help standardize toothbrushing in hospital patients admitted in general. “As the literature on HAP evolves,” concluded Datta, “oral hygiene may take on an indispensable role, similar to hand washing, in preventing and controlling hospital-acquired infections.”

This article was translated from Univadis Italy, which is part of the Medscape Professional Network.

Cite this: Toothbrushing in Hospital Reduces Infections and Death – Medscape – January 12, 2024.