A Cluster-Randomized Controlled Trial of a Multicomponent Intervention Protocol for Pneumonia Prevention Among Nursing Home Elders

Juthani‐Mehta, Manisha; Ness, Peter H. Van; McGloin, Joanne M.; Argraves, Stephanie; Chen, Shu; Charpentier, Peter; Miller, Laura; Williams, Kathleen; Wall, Diane; Baker, Dorothy I.; Tinetti, Mary E.; Peduzzi, Peter; Quagliarello, Vincent

doi:10.1093/cid/ciu935

Cited by 61 publications

(72 citation statements)

References 30 publications

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“…Juthani-Mehta et al (2015) found a similar result among 834 nursing home residents with impaired swallowing function and/or oral hygiene care, who received manual tooth brushing plus a 0.12% chlorhexidine oral rinse, twice per day, together with upright positioning during feeding during in a 2.5 year follow-up study [33]. That study also did not find a reduced incidence of pneumonia, although it was reported that the compliance of the nursing staff with the intervention protocol may have been inadequate for preventing pneumonia.…”

Section: Discussionmentioning

confidence: 90%

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The effect of a daily application of a 0.05% chlorhexidine oral rinse solution on the incidence of aspiration pneumonia in nursing home residents: a multicenter study

et al. 2017

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BackgroundDysphagia and potential respiratory pathogens in the oral biofilm are risk factors for aspiration pneumonia in nursing home residents. The aim of the study was to examine if the daily application of 0.05% chlorhexidine oral rinse solution is effective in reducing the incidence of aspiration pneumonia in nursing home residents with dysphagia. Associations between background variables (age, gender, dysphagia severity, care dependency, medication use, number of medical diagnoses, teeth and dental implants, and wearing removable dentures) and the incidence of aspiration pneumonia were also examined.MethodsThis study is a multicenter study in which for 1 year participants with dysphagia in the intervention group received the usual oral hygiene care with the addition of a 0.05% chlorhexidine oral rinse solution, whereas participants in the control group received only oral hygiene care.ResultsData of 103 participants in 17 nursing homes were analyzed. Survival analysis showed no significant difference in the incidence of pneumonia between both groups (Cox regression, HR = 0.800; 95% CI [0.368–1.737], p = 0.572). Cox regression analysis for Functional Oral Intake Scale (FOIS)-level showed a significant risk of the incidence of pneumonia (HR = 0.804; 95% CI [0.656–0.986], p = 0.036). After adjustment for Group and FOIS-level, Cox multivariate proportional hazard regression analysis showed that the variables age, gender, Care-dependency Scale-score (CDS) number of diseases, medication use, number of teeth, and the presence of dental implants or removable dentures were not significantly associated with the incidence of pneumonia.ConclusionsChlorhexidine oral rinse solution 0.05% as an adjunctive intervention in daily oral hygiene care was not found to reduce incidence of aspiration pneumonia. The requested number of participants to achieve sufficient power was not established and high drop-out rate and non-structural compliance was present. The power was considered to be sufficient to analyze the associations between the background variables and the incidence of pneumonia in the included nursing home residents with dysphagia. Dysphagia was found to be a risk factor for aspiration pneumonia.Trial registrationRegistration in The Netherlands National Trial Register: TC = 3515. Approval for the study was obtained from the Medical Ethical Committee of the Radboud University Medical Center (NL. nr:41,990.091.12).

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Section: Discussionmentioning

confidence: 90%

“…It is unclear whether a higher concentration of chlorhexidine oral rinse solution or using any (safe) chlorhexidine solution is effective to prevent nursing home residents from developing aspiration pneumonia [33, 49]. …”

Section: Discussionmentioning

confidence: 99%

The effect of a daily application of a 0.05% chlorhexidine oral rinse solution on the incidence of aspiration pneumonia in nursing home residents: a multicenter study

et al. 2017

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“…The two high‐quality RCTs in this area (Juthani‐Mehta et al., 2015; Prendergast, Jakobsson, Renvert, & Hallberg, 2012), which tested comprehensive oral care protocols found no effects in favour of the interventions on pneumonia, lower respiratory tract infections or oral health. The UCT trial (Cuccio et al., 2012) rated as of high quality in terms of its conduct (but likewise a design inherently prone to bias) tested an oral care protocol including chlorhexidine rinses and found effects in favour of the intervention on ventilator‐associated pneumonia rates.…”

Section: Resultsmentioning

confidence: 99%

Fundamental nursing care: A systematic review of the evidence on the effect of nursing care interventions for nutrition, elimination, mobility and hygiene

Richards

Hilli

Pentecost

et al. 2018

Journal of Clinical Nursing

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Aims and objectivesTo determine the effects of nursing interventions for people's nutrition, elimination, mobility and hygiene needs.BackgroundPatient experience of health care is sensitive to nursing quality. A refocus on fundamental nursing care is undermined by lack of evidence of effectiveness for interventions in core areas such as elimination, nutrition, mobility and hygiene.DesignSystematic review.MethodsWe searched for and included experimental studies on interventions by professionally qualified and unregistered nurses that addressed participants' nutrition, elimination, mobility and hygiene needs. We extracted data on scope, quality and results of studies followed by descriptive narrative synthesis of included study outcomes using a novel form of harvest plots.ResultsWe included 149 studies, 35 nutrition, 56 elimination, 16 mobility, 39 hygiene and three addressing two or more areas simultaneously (67 randomised controlled trials, 32 non‐randomised controlled trials and 50 uncontrolled trials). Studies into interventions on participant self‐management of nutrition (n = 25), oral health (n = 26), catheter care (n = 23) and self‐management of elimination (n = 21) were the most prevalent. Most studies focussed their outcomes on observational or physiological measures, with very few collecting patient‐reported outcomes, such as quality of life, experience or self‐reported symptoms. All but 13 studies were of low quality and at significant risk of bias. The majority of studies did not define primary outcomes, included multiple measures of identical concepts, used inappropriate analyses and did not conform to standard reporting quality criteria.ConclusionsThe current evidence for fundamental nursing care interventions is sparse, of poor quality and unfit to provide evidence‐based guidance to practising nurses.Relevance to clinical practiceResearchers in nursing internationally should now undertake a programme of work to produce evidence for clinical practice in the fundamentals of care that is reliable, replicable and robust.

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“…Multimodal strategies - Juthani-Metha et al conducted a cluster RCT evaluating the impact of a multimodal intervention protocol for pneumonia prevention among 834 elderly people residing in 36 nursing homes [55]. The study was limited to patients at high risk for pneumonia (residing at a nursing home for at least 1 month, and who had at least one of two risk factors for pneumonia: impaired oral hygiene; swallowing difficulty) which does not represent the entire elderly population residing in nursing homes [56].…”

Section: Measures For Hap Preventionmentioning

confidence: 99%

Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review

Pássaro

Harbarth

Landelle

2016

Antimicrob Resist Infect Control

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BackgroundPneumonia is one of the leading hospital-acquired infections worldwide and has an important impact. Although preventive measures for ventilator-associated pneumonia (VAP) are well known, less is known about appropriate measures for prevention of hospital-acquired pneumonia (HAP).AimThe purpose of this narrative review is to provide an overview of the current standards for preventing HAP in non-ventilated adult patients.MethodsA search of the literature up to May 2015 was conducted using Medline for guidelines published by national professional societies or professional medical associations. In addition, a comprehensive search for the following preventive measures was performed: hand hygiene, oral care, bed position, mobilization, diagnosis and treatment of dysphagia, aspiration prevention, viral infections and stress bleeding prophylaxis.FindingsRegarding international guidelines, several measures were recommended for VAP, whilst no specific recommendations for HAP prevention in non-ventilated patients are available. There is reasonable evidence available that oral care is associated with a reduction in HAP. Early mobilization interventions, swift diagnosis and treatment of dysphagia, and multimodal programmes for the prevention of nosocomial influenza cross-infection, have a positive impact on HAP reduction. The impact of bed position and stress bleeding prophylaxis remains uncertain. Systematic antibiotic prophylaxis for HAP prevention should be avoided.ConclusionScant literature and little guidance is available for the prevention of HAP among non-ventilated adult patients. In addition, the criteria used for the diagnosis of HAP and the populations targeted in the studies selected are heterogeneous. Oral care was the most studied measure and was commonly associated with a decrease in HAP rate, although a broad range of interventions are proposed. No robust evidence is available for other measures. Further high-quality studies are required to evaluate the impact of specific measures on HAP prevention in non-ventilated adult patients.

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A Cluster-Randomized Controlled Trial of a Multicomponent Intervention Protocol for Pneumonia Prevention Among Nursing Home Elders

Abstract: NCT00975780.

Cited by 61 publications

References 30 publications

The effect of a daily application of a 0.05% chlorhexidine oral rinse solution on the incidence of aspiration pneumonia in nursing home residents: a multicenter study

The effect of a daily application of a 0.05% chlorhexidine oral rinse solution on the incidence of aspiration pneumonia in nursing home residents: a multicenter study

Fundamental nursing care: A systematic review of the evidence on the effect of nursing care interventions for nutrition, elimination, mobility and hygiene

Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review

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