Oral Wellness Measures Show Mitigation in Hospital-Acquired Pneumonia

Bacterial pneumonia, medical concept. 3D illustration showing rod-shaped bacteria inside alveoli of the lung.

(Adobe Stock by Dr_Microbe)

Health care–associated infections (HAIs) are regarded as threats to patient safety, and select HAIs are used as metrics by US stakeholders to evaluate care quality.¹ Hospital-acquired pneumonia (HAP), whether ventilator-
associated (VAP) or not (NVHAP), is a common lung infection posing substantial challenges.^2-4 It is linked to extended hospital stays, intensive care unit (ICU) requirements, antibiotic usage, occurrence of sepsis, morbidity, readmission rates within 30 days, elevated health care costs, and mortality.

Findings from a recent case-control study of Medicare beneficiaries showed prolonged hospital stays and costs in the HAP group as well as a likelihood of death 2.8 times greater than that of the control group.⁴ Although intubated patients on mechanical ventilation have a higher risk of developing pneumonia, the mortality rates for patients with VAP and those with NVHAP are similar.⁵ However, most institutions focus on VAP, not NVHAP, due to difficulty defining and tracking the latter condition and limited understanding of its burden and preventability.⁶

Thus, severe pneumonia can be deadly, and survivors may experience short- and long-term pulmonary and extrapulmonary complications. Despite guideline recommendations calling for timely and appropriate antimicrobial treatment, the goal is not being met in managing HAP. Inappropriate use of antibiotics contributes to the development of multidrug-resistant pathogens, and patients with HAP experience high readmission rates within 30 days.^7-9

As the US population ages, preexisting conditions that increase the risk of HAP, such as lung disease and multiple organ system disorders, are likely to become more prevalent.¹⁰ US modeling data from 2010 to 2019 revealed that HAP can serve as a proxy for safety events during the index admission. This finding implies that reducing hospital-acquired adverse events, including HAP, may result in fewer unplanned readmissions.⁹ Therefore, in addition to optimizing HAP treatment with multifaceted interventions, focusing on prevention through improved care—leading to shorter hospital stays—becomes a critical strategy.¹¹

Role of Oral Health in HAP

Ventilator-associated pneumonia (VAP) or not ventilator-associated Pneumonia (NVHAP).

Credit to the Authors

According to the American Dental Association, “Beyond teeth and gums, the mouth serves as a window to the rest of the body and can show signs of infection, nutritional deficiencies, and systemic diseases.”¹² The mouth is a complex ecosystem featuring hard (teeth) and mucus-covered (tongue, lips, cheeks, palate) regions. It is continuously moistened by saliva and, in some areas, gingival fluid, which also provides nutrients to resident microorganisms.

More than 700 bacterial species coexisting with fungi, viruses, archaea, and protozoa form the oral microbiome. The composition of this consortium is influenced by factors such as age, dietary habits, alcohol, tabagism, social status, medications (eg, antibiotics), toxic substances, pregnancy, and hereditary predisposition.¹³

Oral microbiota significantly affect lung microbiota due to anatomical proximity, meaning oral health is closely connected to lung health.13 A systematic review established a consistent association between poor oral health—such as caries and periodontitis—and pneumonia.^14,15 Microbial profile shifts due to poor oral hygiene can occur in all patients with HAP, especially those with dentures. The denture-associated microbiome harbors an abundance of respiratory pathogens potentially protected by oral biofilms against antimicrobial therapy.16

Additionally, it is well-known that the dental plaque in patients with VAP is colonized with Staphylococcus aureus and Pseudomonas aeruginosa, and these pathogens decrease following extubation.¹⁷ Findings from other studies linking poor oral health and pneumonia development highlight the need for rigorous oral care.⁵

Notably, aspiration of oropharyngeal secretions containing respiratory pathogens is considered critical in pneumonia development and portends a dismal prognosis.^15,18 Decreased host immunity, reduced pulmonary flow, oral hygiene, level of alertness, salivary production and flow, and difficulty swallowing can all contribute to aspiration risk.

Compared with patients who can swallow, patients who experience acute stroke with dysphagia are almost 10 times more likely to develop pneumonia.^19,20 However, stroke is not the only cause of dysphagia. Decreased consciousness, delirium, gastroesophageal reflux disease, and mechanical obstruction (eg, esophageal cancer, scarring) are among the other causes. Although there are promising findings from studies suggesting that dysphagia screening can reduce HAP incidence, tools used for this purpose have not been independently validated.²⁰

Prevention of HAP
VAP

Patients who are intubated and on mechanical ventilation for more than 48 hours and then develop pneumonia are diagnosed with VAP, a severe lung infection representing up to 32% of all HAIs and up to 10% of all pediatric device–related infections. Factors contributing to VAP include microbial colonization of the oropharynx or stomach, conditions promoting gastric reflux and aspiration (such as depressed mental status, prone position, and nasogastric tubes), extended intubation, and impediments to pulmonary hygiene (such as thoracic or abdominal surgery and immobilization).²¹

Critical care team members aim to prevent VAP with sets of quality indicators or scientifically proven combined interventions known as bundles. Cuff pressure control, subglottic suctioning, peptic ulcer disease and deep vein thrombosis prophylaxis, semirecumbent positioning, and hand and oral hygiene were the most common components of VAP bundles (Table).^22-24 Results from a systematic review and meta-analysis of different VAP bundles implemented across a variety of ICU settings showed that care bundles without selective oropharyngeal decontamination (SOD) were associated with a 42% reduction in VAP rates. In contrast, the inclusion of SOD in the VAP bundle was associated with a further drop of 70% in VAP rates.^22,25 Because there are conflicting data regarding the use of chlorhexidine gluconate—a cationic antiseptic with broad-spectrum activity against bacteria, fungi, and enveloped viruses—there has been a lack of clarity regarding the adoption of this particular approach to prevent VAP.^26,27 However, a systematic review and meta-analysis of 15 eligible HAP studies (10,742 patients), which included VAP (2033 in the ICU), confirmed that toothbrushing is effective in VAP prevention and should be considered in relevant care bundles.⁵

Reducing VAP cases is crucial, but not all cases are preventable. For instance, ICUs with high numbers of patients with neurosurgical conditions/trauma or homeless individuals with oral health issues will likely not achieve VAP rates of 0%. Maybe the question should be whether institutions serving such high-risk populations could still manage highly effective preventive bundle implementation rates. According to findings from a European study using surveillance data from more than 78,000 participants in 525 ICUs, the answer is yes. Data adjusted for case mixes showed that hospitals with the highest infection rates could prevent more than 50% of their VAP rates, similar to data reported by other institutions.^28-30

NVHAP

NVHAP is a severe lung infection affecting hospitalized patients. It leads to increased antibiotic use, frequent ICU admissions, and a 20% readmission rate for survivors.^31-33 Thus, it is now included in a guideline from The Society of Healthcare Epidemiology of America.³⁴ Addressing NVHAP is crucial, and preventive measures—such as oral care, dysphagia management, and respiratory therapy—can significantly reduce cases.³⁵ Public health strategies such as those used for COVID-19 may also play a preventive role.

Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses to provide oral care) also showed that standardized oral care provided to military veterans in participating health care facilities could decrease pneumonia rates by up to 60%. In 2016, the reduction in NVHAP was estimated to save more than $100,000 in 12-month direct health care costs.¹⁵ Similarly, a single-institution pilot oral care program implemented in 2016 by the Salem VA Medical Center in Salem, Virginia, decreased NVHAP rates by 92%, leading to 13 deaths prevented over 19 months and an estimated cost savings of $2.84 million.¹⁸

Continued education of nursing staff has also been shown to correlate with reduced costs and duration of hospitalization associated with HAP.¹⁹ Results from a separate study also showed that a nurse-driven oral care protocol improved pneumonia outcomes for all adult hospital patients, reducing costs, length of stay, and mortality.²⁰ There is also the need for interprofessional collaboration in implementing nurse skills bundles to reduce HAP risk.¹⁰ This would first involve monitoring head-of-bed elevation, oral hygiene, patient mobility, coughing, and deep breathing to reduce HAP risk.

With the aid of in-house research, nurses may implement oral care using a soft bristle/electric suction toothbrush and toothpaste containing sodium
bicarbonate, use a mouthwash without alcohol to complete oral care, and ensure that dentures are cleaned after each meal and before bedtime. If there are risk factors for aspiration, a nurse may initiate a consultation with a speech therapist, for example, to ascertain a patient’s ability to swallow. Polypharmacy should be discussed with physicians and pharmacists in case some medications could contribute to aspiration risks. Pain relief and nutritional support should also be addressed as appropriate.

The evidence presented in this article does not imply that a combination of consensus-based VAP/NVHAP definitions, interprofessional teams, and preventive care bundles incorporating oral care will drop HAP rates to 0%. This would imply that all forms of HAP are preventable. Instead, it suggests that substantial HAP reductions are realistic. In a world where common antibiotics against superbugs are failing and vaccine refusals are on the rise, implementing HAP preventive care bundles incorporating oral care, where possible, will assume added importance to mitigate often deadly infections.

References

1. Magill SS, O’Leary E, Janelle SJ, et al. Changes in prevalence of health care-associated infections in U.S. hospitals. N Engl J Med. 2018;379(18):1732-1744. doi:10.1056/NEJMoa1801550

2. Shorr AF, Zilberberg MD. Admitting what we do not know about pneumonia readmissions. Chest. 2015;148(1):4-6. doi:10.1378/chest.14-2987

3. Wolfensberger A, Clack L, von Felten S, et al. Implementation and evaluation of a care bundle for prevention of non-ventilator-associated hospital-acquired pneumonia (nvHAP) - a mixed-methods study protocol for a hybrid type 2 effectiveness-implementation trial. BMC Infect Dis. 2020;20(1):603. doi:10.1186/s12879-020-05271-5

4. Baker DL, Giuliano KK, Desmarais M, Worzala C, Cloke A, Zawistowich L. Impact of hospital-acquired pneumonia on the Medicare program. Infect Control Hosp Epidemiol. 2024;45(3):316-321. doi:10.1017/ice.2023.221

5. Ehrenzeller S, Klompas M. Association between daily toothbrushing and hospital-acquired pneumonia: a systematic review and meta-analysis. JAMA Intern Med. 2024;184(2):131-142. doi:10.1001/jamainternmed.2023.6638

6.Jones BE, Sarvet AL, Ying J, et al. Incidence and outcomes of non-ventilator-associated hospital-acquired pneumonia in 284 US hospitals using electronic surveillance criteria. JAMA Netw Open. 2023;6(5):e2314185. doi:10.1001/jamanetworkopen.2023.14185

7. Cillóniz C, Torres A, Niederman MS. Management of pneumonia in critically ill patients. BMJ. 2021;375:e065871. doi:10.1136/bmj-2021-065871

8. Sano M, Shindo Y, Takahashi K, et al. Risk factors for antibiotic resistance in hospital-acquired and ventilator-associated pneumonia. J Infect Chemother. 2022;28(6):745-752. doi:10.1016/j.jiac.2022.02.012

9. Wang Y, Eldridge N, Metersky ML, et al. Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States. JAMA Netw Open. 2022;5(5):e2214586. doi:10.1001/jamanetworkopen.2022.14586

10. Kim BG, Kang M, Lim J, et al. Comprehensive risk assessment for hospital-acquired pneumonia: sociodemographic, clinical, and hospital environmental factors associated with the incidence of hospital-acquired pneumonia. BMC Pulm Med. 2022;22(1):21. doi:10.1186/s12890-021-01816-9

11. Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;32(4):305-314. doi:10.1086/658938

12. Prioritize oral health care in America. News release. American Dental Association. May 23, 2024. Accessed May 31, 2024. https://www.ada.org/about/press-releases/oral-health-legislation-on-capitol-hill

13. Santacroce L, Passarelli PC, Azzolino D, et al. Oral microbiota in human health and disease: a perspective. Exp Biol Med (Maywood). 2023;248(15):1288-1301. doi:10.1177/15353702231187645

14. Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol. 2006;77(9):1465-1482. doi:10.1902/jop.2006.060010

15. Gaeckle NT, Pragman AA, Pendleton KM, Baldomero AK, Criner GJ. The oral-lung axis: the impact of oral health on lung health. Respir Care. 2020;65(8):1211-1220. doi:10.4187/respcare.07332

16. Twigg JA, Smith A, Haury C, et al. Metataxonomic sequencing reveals compositional shifts within the denture-associated microbiome in pneumonia. Research Square. Preprint posted online February 10, 2020. doi:10.21203/rs.2.23022/v1

17. Sands KM, Wilson MJ, Lewis MAO, et al. Respiratory pathogen colonization of dental plaque, the lower airways, and endotracheal tube biofilms during mechanical ventilation. J Crit Care. 2017;37:30-37. doi:10.1016/j.jcrc.2016.07.019

18. Eltringham SA, Kilner K, Gee M, et al. Factors associated with risk of stroke-associated pneumonia in patients with dysphagia: a systematic review. Dysphagia. 2020;35(5):735-744. doi:10.1007/s00455-019-10061-6

19. Chang MC, Choo YJ, Seo KC, Yang S. The relationship between dysphagia and pneumonia in acute stroke patients: a systematic review and meta-analysis. Front Neurol. 2022;13:834240. doi:10.3389/fneur.2022.834240

20. Livesey A, Quarton S, Pittaway H, et al. Practices to prevent non-ventilator hospital acquired pneumonia: a narrative review. J Hosp Infect. Published online April 23, 2024. Accessed July 21, 2024. doi:10.1016/j.jhin.2024.03.019

21. Kohbodi GA, Rajasurya V, Noor A. Ventilator-associated pneumonia. StatPearls. StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK507711/

22. Mastrogianni M, Katsoulas T, Galanis P, Korompeli A, Myrianthefs P. The impact of care bundles on ventilator-associated pneumonia (VAP) prevention in adult ICUs: a systematic review. Antibiotics (Basel). 2023;12(2):227. doi:10.3390/antibiotics12020227

23. Quick safety issue 61: preventing non-ventilator hospital-acquired pneumonia. The Joint Commission. September 13, 2021. Accessed June 2, 2024. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-61/

24. .Keyt H, Faverio P, Restrepo MI. Prevention of ventilator-associated pneumonia in the intensive care unit: a review of the clinically relevant recent advancements. Indian J Med Res. 2014;139(6):814-821.

25. Landelle C, Nocquet Boyer V, Abbas M, et al. Impact of a multifaceted prevention program on ventilator-associated pneumonia including selective oropharyngeal decontamination. Intensive Care Med. 2018;44(11):1777-1786. doi:10.1007/s00134-018-5227-4

26. Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis. 2011;11(11):845-854. doi:10.1016/S1473-3099(11)70127-X

27. Price R, MacLennan G, Glen J; SuDDICU Collaboration. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. BMJ. 2014;348:g2197. doi:10.1136/bmj.g2197

28. Lambert ML, Silversmit G, Savey A, et al. Preventable proportion of severe infections acquired in intensive care units: case-mix adjusted estimations from patient-based surveillance data. Infect Control Hosp Epidemiol. 2014;35(5):494-501. doi:10.1086/675824

29. Kallet RH. The vexing problem of ventilator-associated pneumonia: observations on pathophysiology, public policy, and clinical science. Respir Care. 2015;60(10):1495-1508. doi:10.4187/respcare.03774

30. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32(2):101-114. doi:10.1086/657912

31. .Klompas M. Hospital-acquired pneumonia in nonventilated patients: the next frontier. Infect Control Hosp Epidemiol. 2016;37(7):825-826. doi:10.1017/ice.2016.101

32. Giuliano KK, Baker D. Sepsis in the context of nonventilator hospital-acquired pneumonia. Am J Crit Care. 2020;29(1):9-14. doi:10.4037/ajcc2020402

33. Baker DL, Giuliano KK. Prevention practices for nonventilator hospital-acquired pneumonia: a survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN). Infect Control Hosp Epidemiol. 2022;43(3):379-380. doi:10.1017/ice.2021.427

32. Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43(6):687-713. doi:10.1017/ice.2022.88

33. Wolfensberger A, Clack L, von Felten S, et al. Prevention of non-ventilator-associated hospital-acquired pneumonia in Switzerland: a type 2 hybrid effectiveness-implementation trial. Lancet Infect Dis. 2023;23(7):836-846. doi:10.1016/S1473-3099(22)00812-X

34. Quick safety issue 61: preventing non-ventilator hospital-acquired pneumonia. The Joint Commission. September 13, 2021. Accessed June 2, 2024. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-61/

35. Keyt H, Faverio P, Restrepo MI. Prevention of ventilator-associated pneumonia in the intensive care unit: a review of the clinically relevant recent advancements. Indian J Med Res. 2014;139(6):814-821.