FOCUS ON INFECTION PREVENTION The Breadth of Hospital-Acquired Pneumonia: Nonventilated versus Ventilated Patients in Pennsylvania James Davis, BSN, RN, CCRN, CIC INTRODUCTION areas of the hospital. The intensive care Senior Infection Prevention Analyst unit (ICU) is one such care area where Hospital-acquired pneumonia (HAP), Edward Finley, BS resources, such as specially trained staff, Data Analyst according to the Centers for Disease Pennsylvania Patient Safety Authority Control and Prevention (CDC), “has ventilators, and interventions, could be accounted for approximately 15% of all matched to patient needs. hospital-associated infections.”1 HAP The CDC provides a surveillance defini- taxonomy separates event cases into tion for VAP and modules in the National those patients requiring mechanical ven- Healthcare Safety Network (NHSN) that ABSTRACT tilation and those who do not require enable VAP infection tracking. Standard- Considering the evolution of measures ventilator support. A patient receiving ized surveillance case definitions and designed to prevent nosocomial pneu- mechanical ventilation who is confirmed a searchable national database provide monia, it makes clinical and financial to have nosocomial pneumonia while information for calculating the projected sense to focus efforts on patients on the ventilator is classified as having costs of VAP. Therefore, VAP is an iden- who require mechanical ventilation. ventilator-associated pneumonia (VAP). tifiable, trackable, fiscally measurable Patients at risk for ventilator-associated For the purpose of this article, a patient target with evidence-based preventive care pneumonia (VAP) are easily identified who develops nosocomial pneumonia bundles that can be applied with focused because they require an endotracheal and is not ventilated is classified as having resources. The Institute for Healthcare tube or tracheostomy, require life sup- nonventilator-HAP (NV-HAP). The most Improvement states that “many hospitals port, and are commonly admitted to recent CDC guideline for preventing HAP have achieved significant reductions in specific areas of the hospital. However, identifies that “the primary risk factor for VAP rates in their critical care units, some Pennsylvania data reveals that mortality the development of hospital-associated even reaching zero by taking a compre- rates for patients with nonventilator- bacterial pneumonia is mechanical ven- hensive and multidisciplinary approach to hospital-acquired pneumonia (NV-HAP) tilation.”1 The CDC guideline stated ventilator care.”3 Pennsylvania hospitals are comparable to mortality rates for that some reports showed that “patients have shown impressive VAP rate reduc- patients with VAP Using Pennsylvania . receiving continuous mechanical ventila- tions with the adoption of the adult VAP data, Pennsylvania Patient Safety tion had 6-21 times the risk of developing bundle and innovation by way of develop- Authority analysts have also determined hospital-associated pneumonia compared ing evidence-based practices in the form that NV-HAP affects more people than with patients who were not receiving of neonatal and pediatric VAP prevention VAP and is as lethal as and more costly mechanical ventilation.”1 Furthermore, bundles.4 Literature suggests that VAP than VAP Furthermore, NV-HAP is a . CDC identified that “because of this bundles positively impact VAP infection safety issue that is on the rise in patients tremendous risk, in the last two decades, rates; however, VAP is not the only piece in the conventional ward, and it is likely most of the research on hospital-associated in the nosocomial pneumonia puzzle. to be underreported. Data suggests that pneumonia has been focused on VAP.”1 if VAP prevention is a focus at a facility, Literature highlighting incidence and METHODS perhaps NV-HAP prevention should also outcome data with regard to NV-HAP is Pennsylvania state law requires that share the spotlight. (Pa Patient Saf Advis sparse. Esperatti et al. hypothesized that all healthcare-associated infections are 2012 Sep;9[3]:99-105.) this lack of data “may be caused in part reported through NHSN. Pennsylvania by the dispersion of cases within hospital Patient Safety Authority analysts queried wards, hindering surveillance.”2 NHSN for complete nosocomial pneu- monia data sets from calendar years 2009 BACKGROUND through 2011, inclusive of the total inpa- Considering the evolution of measures tient population for Pennsylvania acute designed to prevent nosocomial pneu- care facilities. Analysts also extracted data Scan this code monia, it makes clinical and financial for nosocomial pneumonia that con- with your mobile sense to focus efforts on patients who tributed to death during that same time device’s QR require mechanical ventilation. Patients period. Of those cases in which nosoco- reader to access at risk for VAP are easily identified mial pneumonia contributed to death, the Authority's because they require an endotracheal tube ventilator status was also extracted. Time toolkit on this topic. or tracheostomy, require life support, series data was aggregated into yearly sub- and are commonly admitted to specific totals and a final total for analysis. Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 99 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Table 1. Pennsylvania Nosocomial Pneumonia and Related Deaths NO. OF NO. OF NO. NO. NV-HAP NV-HAP % OF NV-HAP CASES OF VAP OF VAP % OF VAP CASES YEAR CASES DEATHS CONTRIBUTING TO DEATH CASES DEATHS CONTRIBUTING TO DEATH 2009 1,976 363 18.4 (95% CI: 16.5 to 20.3) 922 163 17.7 (95% CI: 15.0 to 20.5) 2010 1,848 366 19.8 (95% CI: 17.8 to 21.8) 737 144 19.5 (95% CI: 16.3 to 22.7) 2011 1,773 315 17.8 (95% CI: 15.8 to 19.7) 640 127 19.8 (95% CI: 16.4 to 23.3) Total 5,597 1,044 18.7 (95% CI: 17.5 to 19.8) 2,299 434 18.9 (95% CI: 17.1 to 20.7) Note: NV-HAP refers to nonventilator-hospital-acquired pneumonia and VAP refers to ventilator-associated pneumonia. RESULTS hypoxic episodes more often than patients safeguards against pathogen invasion. Part Table 1 shows the number of NV-HAP with VAP.7 Their apparent observation of the pathogenesis of HAP involves the and VAP cases for 2009, 2010, and 2011 is important given the potential damage oral cavity as a source and reservoir for from NHSN, with the total for all three repeated hypoxic episodes may have on bacteria that may then cause systemic dis- years. Also included in the table is the a patient’s well-being. Because NV-HAP ease. Li et al. noted that “the teeth are the yearly and combined totals for deaths is on the rise in patients cared for in the only nonshedding surfaces in the body, related to either VAP or NV-HAP. Table conventional ward and tends to be under- and bacterial levels can reach more than 1 also depicts the percentage of patients reported, NV-HAP may become more 1011 microorganisms per mg of dental for which NV-HAP or VAP contributed costly if prevention efforts continue to plaque.”10 The presence of subgingival bio- to their deaths. Comparing the data year focus largely on VAP. film serves as a continual and enormous to year, considering the confidence inter- bacterial load.10 vals, there were no statistically significant Etiology of HAP Pathogenic organisms in the oropharynx differences between the two groups. The Major factors that increase the patient’s may be endogenous or exogenous. Endoge- mortality rates for patients with NV-HAP risk for pneumonia include aspiration, nous pathogens may be present secondary and VAP were comparable. stroke (because of impaired swallowing to the patient’s dental state, underlying NV-HAP has the potential to be more function or diminished gag reflex), older comorbidities, or overgrowth from recent costly than VAP. Table 2 depicts a com- age, altered level of consciousness (for antibiotic use. Exogenous pathogens may parison of the estimated costs for VAP example, due to medications, substance be present from the patient’s native envi- and NV-HAP cases5 over three years abuse, or seizure), gastroesophageal reflux ronment, the hospital environment, or in Pennsylvania. disease, and poor oral hygiene.8 For infec- medical devices (such as suction catheters tion to occur, several conditions need to and endotracheal tubes [ETTs]) and due to occur in succession. These conditions are inadequate hand hygiene, cross-contami- DISCUSSION referred to as the chain of infection.9 Those nation, or translocation. Poor oral hygiene As previously noted,1 the majority of conditions needed to complete the chain increases plaque load, which increases the knowledge related to HAP has focused of infection include the following: level of enzymes in saliva.10 Furthermore, on VAP. VAP is an important subset of an increased presence of oral proteolytic 1. Pathogen in sufficient numbers HAP; however, if the hypothesis noted by enzymes may change the lining of the (dose) Esperatti et al. is valid, the true incidence mouth, increasing attachment and colo- of NV-HAP may be underestimated. In a 2. Pathogen of sufficient virulence nization by exogenous or endogenous multicenter study of NV-HAP in patients 3. Susceptible host pathogenic bacteria.11 cared for outside of the ICU, Sopena 4. Mode of transmission or transfer of and Sabrià realized that the number of For a host to be susceptible, immunity the pathogen from source (reservoir) patients with nosocomial pneumonia is needs to be adversely affected. Inter- to host increasing in the conventional hospital rupting the first line of human defense 5. Portal of entry into the host to bacterial invasion may result in sig- ward.6 Werarak et al. noted in their study Major risk factors for pneumonia nificant insult that could easily lead to that the differences in outcomes related understandably allude to the oronaso- HAP. Mechanical defenses include an to NV-HAP and VAP are not significant; pharynx, oral cavity, and maintenance intact, moist, and healthy oral lining and however, NV-HAP patients did experience of functional, chemical, and mechanical mucosa. Healthy, intact oral epithelial Page 100 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority Table 2. Estimated Costs of NV-HAP and VAP Cases treatment and preventive care. The same line of reasoning holds true for those who NO. OF NV- COST FOR NV- NO. OF COST FOR VAP YEAR HAP CASES HAP CASES VAP CASES CASES practice medical and surgical dentistry and for the registered dental hygienist. The 2009 1,976 $55,343,808 922 $34,521,524 dental professional may be a missing link 2010 1,848 $51,758,784 737 $27,594,754 in the chain of HAP prevention. 2011 1,773 $49,658,184 640 $23,962,880 Total 5,597 $156,760,776 2,299 $86,079,158 NV-HAP PREVENTION STRATEGIES Note: NV-HAP refers to nonventilator-hospital-acquired pneumonia and VAP refers to ventilator-asso- ciated pneumonia. The estimated average cost per NV-HAP case is $28,008. The estimated average cost per VAP case is $37,442. Average costs derived from the following study: Kalsekar I, Amsden J, Plotting a Course Kothari S, et al. Economic and utilization burden of hospital-acquired pneumonia (HAP): a systematic review and meta-analysis. Chest 2010 Oct;138(4_MeetingAbstracts):739A. VAP was discussed as a logical place to start the battle against HAP; however, cells not only provide a physical barrier included mechanical or topical chemical NV-HAP requires a different approach. against infection but are capable of medi- disinfection (or both) or topical oral anti- The population of patients who may ating a chemical response to the invasion biotic use.13 Paju and Scannapieco state develop NV-HAP could prove to be quite of pathogenic bacteria.12 Functional that “institutionalized but non-ventilated large—are there focal points for implement- cilia in the nares and healthy mucosa patients . . . appear to benefit from ing preventive measures? To assist the help limit intrusion of inhaled potential improved oral care by showing lower levels clinician in focusing efforts on care areas, pathogens from entering the airway. The of oral bacteria and fewer pneumonia Authority analysts looked to the data. presence of an intact cough and gag reflex episodes and febrile days.”14 A statistically Table 3 provides a view of NV-HAP by also protects the patient from aspiration significant difference (p = 0.044) in oral NHSN location type for Pennsylvania, by of oral contents into the lungs. Given hygiene index (OHI) scores among indi- pooled mean and percentiles. This table is the list of major risk factors for HAP, one viduals with respiratory disease and those presented in a format similar to an NHSN can easily realize how the innate immune with no disease has been noted by Scan- report. The Authority analysts chose to use system may be compromised in an at-risk napieco et al.15 Furthermore, individuals patient-days as the unit-specific denomina- patient. Therefore, patients at risk for with median OHI scores are 1.3 times tor for the development of this analysis. HAP are susceptible hosts. as likely to have respiratory disease, and The Authority’s choice of denominator The mode of transmission has been par- those with maximum OHI scores are 4.5 was limited by the constraints of available tially explained during the discussion of times as likely to have respiratory disease.15 data. Analysis by patient-days may underes- oral colonization of potential pathogens timate the true rate of NV-HAP since this and biofilm as a constant reservoir. The The Dental Professional metric potentially lowers rates in regard bacteria are transferred from the oral Healthcare settings depend on teamwork to extensions of length of stay related to cavity into the lungs because of lapses to drive positive patient outcomes; a mul- NV-HAP. Authority analysts did not have in basic host defenses. In VAP cases, the tidisciplinary approach for planning care access to unit-level specific admissions internal and external lumens of the ETT is essential for delivering effective complex by location type for this analysis, hence or tracheostomy tube may become cov- care. A multidisciplinary approach is also the use of patient-days by location type. ered in biofilm contributing to bacterial essential for preventing complications Rates in Table 3 are reflected as per 1,000 transfer as well as aspiration of subglottic associated with exposure to the healthcare patient-days. secretions containing bacteria derived setting, such as HAP. Adachi et al. corre- from oral plaque biofilm. The portal lated weekly dental cleaning by a hygienist Targeted Intervention of entry into the host is the oral cavity, with less fever and fatal pneumonia.16 In a After a patient population or unit is the aerodigestive tract, and the ETT or similar study, Abe et al. noted a reduction identified at the facility level, proven tracheostomy tube, if present, thereby in influenza infection related to weekly interventions and lessons derived from completing the chain to HAP. professional dental cleaning.17 VAP prevention activities can be applied Just as a cardiologist is consulted to care for to the NV-HAP patient. Selected inter- Oral Hygiene a patient with an underlying heart condi- ventions from the literature that may be During a systematic literature review, tion even though a cardiac condition may applicable to the NV-HAP population are Scannapieco et al. noted a 40% decrease not be the primary reason for admission, reflected in the Figure. in HAP with combined interventions that a cardiologist’s expertise is utilized to plan (continued on page 105) Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 101 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Table 3. Distribution of NV-HAP Cases (based on aggregate data for Pennsylvania for 2009, 2010, and 2011) NO. OF NO. OF LOCA- NV-HAP PATIENT- POOLED UNIT TYPE* TIONS CASES DAYS MEAN†,‡ PERCENTILE‡,§ (Median) 10% 25% 50% 75% 90% Critical Care Neurologic 3 11 40,512 0.272 0.247 Cardiothoracic 33 216 930,991 0.232 0.062 0.133 0.210 0.363 0.484 Surgery 16 154 670,509 0.230 0.040 0.121 0.210 0.330 0.459 Trauma 11 107 515,252 0.208 0.153 0.183 0.207 0.286 0.319 Medical/surgical 137 848 4,480,656 0.189 0.000 0.051 0.123 0.249 0.449 Neurosurgical 8 85 454,838 0.187 0.139 Cardiac 29 131 927,286 0.141 0.000 0.038 0.109 0.195 0.330 Medical 31 190 1,364,397 0.139 0.016 0.056 0.099 0.246 0.347 Burn 4 7 82,443 0.085 0.082 Respiratory 2 4 65,637 0.061 0.080 Cardiothoracic 3 8 180,915 0.044 0.000 pediatric Nursery 24 25 1,049,229 0.024 0.000 0.000 0.000 0.022 0.071 Medical/surgical 6 7 343,164 0.020 0.004 pediatric Ward Genitourinary 3 12 124,972 0.096 0.110 Neurologic 9 39 410,219 0.095 0.078 Pulmonary 4 32 359,703 0.089 0.071 Neurosurgical 8 27 354,410 0.076 0.075 Surgical 48 312 4,209,299 0.074 0.000 0.037 0.069 0.113 0.168 Vascular surgery 2 5 70,231 0.071 0.060 Medical/surgical 152 1673 23,904,085 0.070 0.000 0.018 0.052 0.096 0.158 Medical 58 507 8,064,412 0.063 0.000 0.019 0.035 0.070 0.116 Orthopedic 50 133 2,145,512 0.062 0.000 0.000 0.044 0.093 0.186 Gynecology 8 3 157,176 0.019 0.000 Gerontology 2 2 118,333 0.017 0.023 Behavioral 110 90 8,258,652 0.011 0.000 0.000 0.000 0.015 0.075 Medical pediatric 4 5 472,100 0.011 0.002 Orthopedic 3 1 95,976 0.010 0.000 pediatric Nursery 79 10 1,362,609 0.007 0.000 0.000 0.000 0.000 0.000 Page 102 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority Table 3. Distribution of NV-HAP Cases (based on aggregate data for Pennsylvania for 2009, 2010, and 2011) (continued) NO. OF NO. OF LOCA- NV-HAP PATIENT- POOLED UNIT TYPE* TIONS CASES DAYS MEAN†,‡ PERCENTILE‡,§ (Median) 10% 25% 50% 75% 90% Behavioral health 12 2 302,401 0.007 0.000 0.000 0.000 0.000 0.007 pediatric Postpartum 63 12 1,944,665 0.006 0.000 0.000 0.000 0.000 0.026 Rehabilitation 5 1 176,551 0.006 0.069 pediatric Medical/surgical 44 5 959,543 0.005 0.000 0.000 0.000 0.000 0.000 pediatric Behavioral health 11 2 417,412 0.005 0.000 0.000 0.000 0.000 0.014 adolescent Labor & delivery/ 43 4 837,294 0.005 0.000 0.000 0.000 0.000 0.000 postpartum Labor & delivery 22 1 426,176 0.002 0.000 0.000 0.000 0.000 0.000 Rehabilitation 82 163 5,649,493 0.029 0.000 0.000 0.020 0.062 0.128 Specialty Care Area Bone marrow 5 33 291,857 0.113 0.133 transplant Hematology/ 16 172 1,905,141 0.090 0.000 0.025 0.063 0.110 0.192 oncology Solid organ 1 2 24,645 0.081 0.081 transplant Hematology/ 4 13 297,827 0.044 0.024 oncology pediatric Solid organ 1 1 83,559 0.012 0.012 transplant pediatric Step-Down Unit Adult 73 379 5,332,998 0.071 0.000 0.010 0.046 0.102 0.156 Nursery 23 12 484,825 0.025 0.000 0.000 0.000 0.044 0.114 Pediatric 4 2 190,271 0.011 0.010 Long-Term Acute Care 28 117 2,688,812 0.044 0.000 0.000 0.020 0.073 0.122 Note: NV-HAP refers to nonventilator-hospital-acquired pneumonia. Locations that are not represented reported no events. * Units are based on National Healthcare Safety Network classifications. † Pooled mean = total infections ÷ total patient-days x 1000 ‡ Per 1000 patient-days § For locations that have less than 10 units, reporting percentile distributions have not been calculated. Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 103 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Figure. Selected Interventions to Prevent Nonventilator-Hospital-Acquired Pneumonia Selected interventions to prevent colonization: Provide information about optimal pulmonary state. Optimize functional reserve capacity. Strengthen patient’s resistance to atelectasis. Maintain patient’s resistance to infection: — Perform hand hygiene. — Institute a routine oral hygiene regimen. — Eliminate oral bacterial reservoirs. — Consult with a dental professional. — Protect oral epithelial cells and nasal passages by providing moisture and avoiding large-bore nasogastric tubes. — Avoid unnecessary antibiotics. — Avoid unnecessary stress ulcer prophylaxis (if necessary, consider a cytoprotective agent). — Consider chlorhexidine oral rinse or chlorhexidine bath for select patient populations. Selected interventions to prevent aspiration: Teach techniques for optimizing cough and airway clearance. Avoid unnecessary medications that reduce level of consciousness. Maintain head of the bed at 30 degrees or greater unless contraindicated. Encourage ambulation. Provide subglottic suctioning. Consult with speech and/or swallowing professionals when appropriate. Holistic prevention strategies: Administer vaccines and immunizations. Evaluate the patient’s risk for aspiration. Provide smoking cessation counseling. Provide dementia screening. Institute environmental infection control measures. Assess the patient’s nutritional status. MS12456 Encourage personal hygiene, including hand hygiene. Encourage routine professional dental care. Notes Abe S, Ishihara K, Adachi M, et al. Professional oral care reduces influenza infection in elderly. Arch Gerontol Geriatr 2006 Sep-Oct;43(2):157-64. Adachi M, Ishihara K, Abe S, et al. Effect of professional oral health care on the elderly living in nursing homes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002 Aug;94(2):191-5. Institute for Healthcare Improvement (IHI). Prevent ventilator-associated pneumonia [website]. [cited 2012 Mar 30]. Cambridge (MA): IHI. http://www.ihi.org/ explore/VAP/Pages/default.aspx. Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for nosocomial bacterial pneumonia and chronic obstructive pulmonary disease. A systematic review. Ann Periodontol 2003 Dec;8(1):54-69. Scannapieco FA, Papandonatos GD, Dunford RG. Associations between oral conditions and respiratory disease in a national sample survey population. Ann Periodontol 1998 Jul;3(1):251-6. Successful reduction of ventilator-associated pneumonia. Pa Patient Saf Advis [online] 2009 Jun [cited 2012 Mar 30]. http://patientsafetyauthority.org/ ADVISORIES/AdvisoryLibrary/2009/Jun6(2)/Pages/63.aspx. Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care-associated pneumonia, 2003. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee [online]. 2003 [cited 2012 Mar 30]. http://www.cdc.gov/hicpac/pdf/guidelines/HApneu2003guidelines.pdf. Page 104 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority (continued from page 101) mouth. Furthermore, if oral hygiene is dental professional may prove essential in compromised, the oral cavity and naso- preventing NV-HAP (and VAP). NV-HAP CONCLUSION pharyngeal tract will serve as a constant in Pennsylvania may potentially have a The chain of infection that perpetuates reservoir of pathogens. greater impact than VAP. If VAP preven- HAP can be broken with appropriate Currently, NV-HAP bundles are lacking tion is a focus at a facility, perhaps the interventions. In the case of VAP, the in the peer-reviewed literature. Focusing prevention of NV-HAP—which has the majority of interventions are aimed at care on reservoirs and the portal of entry potential to affect more patients, be more reducing the risk for aspiration, decolo- may be the most realistic approach for costly, and be as lethal as VAP—deserves nizing the oral cavity, maintaining the preventing NV-HAP at this time. Improv- to share the spotlight. aerodigestive tract, and protecting the ing oral hygiene and collaborating with a NOTES 1. Tablan OC, Anderson LJ, Besser R, et 6. Sopena N, Sabrià M. Neunos 2000 11. Childs WC 3rd, Gibbions RJ. Selective al. Guidelines for preventing health- Study Group. Multicenter study of modulation of bacterial attachment to care-associated pneumonia, 2003. hospital-acquired pneumonia in non-ICU oral epithelial cells by enzyme activities Recommendations of CDC and the patients. Chest 2005 Jan;127(1):213-9. associated with poor oral hygiene. J Healthcare Infection Control Practices 7. Werarak P, Kiratisin P, Thamlikitkul Periodontal Res 1990 May;25(3):172-8. Advisory Committee [online]. 2003 [cited V. Hospital-acquired pneumonia and 12. Sugawara S, Uehara A, Tamai R, et al. 2012 Mar 30]. http://www.cdc.gov/ ventilator-associated pneumonia in adults Innate immune responses in oral mucosa. hicpac/pdf/guidelines/ at Siriraj Hospital: etiology, clinical J Endotoxin Res 2002 Dec;8(6):465-8. HApneu2003guidelines.pdf. outcomes, and impact of antimicrobial 13. Scannapieco FA, Bush RB, Paju S. Asso- 2. Esperatti M, Ferrer M, Theessen A, resistance. J Med Assoc Thai 2010 Jan;93 ciations between periodontal disease and et al. Nosocomial pneumonia in the Suppl 1:S126-38. risk for nosocomial bacterial pneumonia intensive care unit acquired by mechani- 8. Shigemitsu H, Afshar K. Aspiration and chronic obstructive pulmonary dis- cally ventilated versus nonventilated pneumonias: under-diagnosed and ease. A systematic review. Ann Periodontol patients. Am J Respir Crit Care Med 2010 under-treated. Curr Opin Pulm Med 2003 Dec;8(1):54-69. Dec;182(12):1533-9. 2007;13(3):192-8. Also available at http:// 14. Paju S, Scannapieco FA. Oral biofilms, 3. Institute for Healthcare Improvement www.medscape.com/viewarticle/ periodontitis, and pulmonary infections. (IHI). Prevent ventilator-associated pneu- 556082_print. Oral Dis 2007 Nov;13(6):508-12. monia [website]. [cited 2012 Mar 30]. 9. Sehulster LM, Chinn RYW, Arduino 15. Scannapieco FA, Papandonatos GD, Cambridge (MA): IHI. http://www.ihi. MJ, et al. Guidelines for environmental Dunford RG. Associations between oral org/explore/VAP/Pages/default.aspx. infection control in health-care facili- conditions and respiratory disease in a 4. Successful reduction of ventilator- ties. Recommendations of CDC and the national sample survey population. Ann associated pneumonia. Pa Patient Saf Healthcare Infection Control Practices Periodontol 1998 Jul;3(1):251-6. Advis [online] 2009 Jun [cited 2012 Mar Advisory Committee (HICPAC) [online]. 16. Adachi M, Ishihara K, Abe S, et al. Effect 30]. http://patientsafetyauthority.org/ 2003 [cited 2012 April 4]. http://www. of professional oral health care on the ADVISORIES/AdvisoryLibrary/2009/ cdc.gov/hicpac/pdf/guidelines/ elderly living in nursing homes. Oral Surg Jun6(2)/Pages/63.aspx. eic_in_HCF_03.pdf. Oral Med Oral Pathol Oral Radiol Endod 5. Kalsekar I, Amsden J, Kothari S, et al. 10. Li X, Kolltveit KM, Tronstad L, et al. 2002 Aug;94(2):191-5. Economic and utilization burden of Systemic diseases caused by oral infection. 17. Abe S, Ishihara K, Adachi M, et al. hospital-acquired pneumonia (HAP): a Clin Microbiol Rev 2000 Oct;13(4):547-58. Professional oral care reduces influenza systematic review and meta-analysis. Chest Also available at http://cmr.asm.org/ infection in elderly. Arch Gerontol Geriatr 2010 Oct;138(4_MeetingAbstracts):739A. content/13/4/547.full. 2006 Sep-Oct;43(2):157-64. Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 105 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 3—September 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. 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