Oral Hygiene Interventions for the Prevention of Healthcare-Associated Infections and the Impact of Healthcare-Associated Infections on Patients Hospitalized With Oropharyngeal Cancers of Lip, Mouth, and Pharynx.
Poolakkad Sankaran, Satheesh Kumar
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CitationPoolakkad Sankaran, Satheesh Kumar. 2020. Oral Hygiene Interventions for the Prevention of Healthcare-Associated Infections and the Impact of Healthcare-Associated Infections on Patients Hospitalized With Oropharyngeal Cancers of Lip, Mouth, and Pharynx.. Master's thesis, Harvard Medical School.
AbstractThesis Project 1 - Oral Hygiene Interventions for the Prevention of Healthcare-Associated Infections
Paper 1- Abstract (Enhanced oral hygiene interventions as a risk mitigation strategy for the prevention of non-ventilator associated pneumonia: A systematic review and meta-analysis of randomized controlled trials and non-randomized trials. )
Background: Health care-acquired pneumonia is a significant risk for nursing home and hospital patients. While oral care interventions (OCI) have been found to be effective in reducing the risk of ventilator-associated pneumonia (VAP), their utility in mitigating non-ventilator-associated pneumonia (NVAP) remains unknown. We performed a structured meta-analysis of randomized and non-randomized clinical trials of enhanced oral hygiene procedures on NVAP.
Methods: We searched PubMed and Embase to include clinical trials (randomized and non-randomized), and observational (retrospective and prospective), and quasi-experimental studies examining the effect of any method of OCI on the incidence of NVAP.
Results: After quality assessment and consensus agreement between authors we synthesized 6 randomized clinical trials (RCTs) (3891 patients), two non-randomized trials (2993 patients); and separately assessed a retrospective trial (143 patients) and a quasi-experimental study (83 patients). Most studies, performed in nursing homes, did not show a significant association between OCI and NVAP prevention (RR random 0.89, 95% CI 0.64-1.25, p-value 0.50). Likewise, the non-randomized trials failed to show an association between NVAP risk and OCI (RR random 1.42, 95% CI, 0.70-2.88, p-value 0.32). However, in the subgroup analysis comparing dental professional involvement in care vs usual care, reduced NVAP risk was demonstrated (RR random 0.65,95% CI 0.43-0.98, p-value 0.03).
Conclusions: Study results suggest that professional dental care may have some benefit among NVAP patients. The lack of consistent OCI protocols, data in hospitalized patients and robust RCTs do not allow definitive conclusions about the contribution of OCI in mitigating NVAP risk.
Paper 2- Abstract (Network meta-analysis to assess the comparative effectiveness of oral care interventions in preventing ventilator-associated pneumonia in critically ill patients)
Background: In this research, we assessed the efficacy of a novel analytic network metanalysis (NMA) in creating a hierarchy to define the most effective oral care intervention (OCI) for the prevention and management of ventilation-associated pneumonia (VAP).
Methods: We applied NMA to a previously published robust pairwise meta-analysis (PMA). Statistical analyses were based on comparing rates of total VAP events between intervention groups and placebo-usual care groups. We synthesized a netgraph, reported ranking order of the treatment, and summarized our output by a forest plot with a reference treatment placebo/usual care.
Results: With our inclusion and exclusion criteria for the NMA, we extracted 25 studies (4473 subjects). The NMA included 16 treatments, 29 pairwise comparisons, and 15 designs. Based on the results of multiple comparisons with frequentist ranking probability P scores, tooth brushing (P score fixed of 0.94, P score random of 0.89), toothbrushing with povidone-iodine (P score fixed of 0.91, P score random 0.88), and furacillin (P score set of 0.88, P score random 0.84) were the best three interventions for preventing VAP.
Conclusion: NMA appeared to be an effective platform from which multiple interventions reported in disparate clinical trials could be compared to derive a hierarchical assessment of efficacy in the intervention of VAP. According to the NMA outcome, toothbrushing alone or toothbrushing along with a potent antiseptic mouthwash povidone-iodine was related to the highest response rate in preventing VAP in critically ill patients, followed by furacillin and chlorhexidine 0.2%, respectively.
Thesis Project 2 - The Impact of Healthcare-Associated Infections on Patients Hospitalized With Oropharyngeal Cancers of Lip, Mouth, and Pharynx.
Background: Healthcare-Associated Infections (HAIs) increases the burden of illness by the increased length of stay, cost of hospital expenses, and risk of mortality. Oropharyngeal cancer patients are at increased risk of HAIs due to multiple therapeutic interventions and due to the presence of an enormous number of microorganisms in the oro-pharyngeal areas responsible for HAIs. We tried to assess the 2017 trend in differences in outcome among patients with a primary diagnosis of malignant neoplasms of lip, oral cavity, and pharynx (MLOP) with and without HAI.
Methods: Using the United States (U.S.), the National inpatient sample (NIS) database of 2017, we identified all hospitalization with a primary diagnosis of malignant neoplasms of lip, oral cavity, and pharynx and identified the HAIs among them. We assessed the difference in the cost, length of stay (LOS), and in-hospital mortality among MLOP cancer patients with and without HAI. Association between outcomes (in-hospital mortality, LOS, and hospital charges) and independent variables examined using survey specific multivariable regression analyses.
Result: Among 7,159, 694 (weighted numbers - 20% of the total patients admitted in the U.S. hospitals in the year 2017), 54,934 (unweighted numbers in the U.S.) discharged with a primary diagnosis of the MLOP. Among those 54,934 MLOP patients, 555 (unweighted numbers in the U.S.) patients acquired a minimum of one HAI during their in-hospital stay. The most common HAI was Clostridium difficile infection (36%), followed by central line-associated bloodstream infection (32%), ventilator-associated pneumonia (17%), and catheter-associated urinary tract infection (15%). MLOP patients with HAI had LOS of 6.63 days longer than the non-HAI MLOP patients, confidence intervals (C.I.s), 3.62-9.64, p < 0.0001. MLOP patient with HAI had hospitalization charges of 49,383 USD higher than the non-HAI MLOP patients, CIs 20144 USD- 78622 USD, p < 0.0001. Mortality was not significantly different among HAI and non-HAI MLOP patients, Odds ratio (OR) 0.63, C.I.s, 0.22- 1.81, a p-value of 0.4.
Conclusion : MLOP patients who acquired HAI were associated with a considerable increase in the length of stay and total charges during their in-hospital stay.
Citable link to this pagehttps://nrs.harvard.edu/URN-3:HUL.INSTREPOS:37365238