机械通气危重症患者氯己定含漱后口咽部细菌定植。
Oropharyngeal Bacterial Colonization after Chlorhexidine Mouthwash in Mechanically Ventilated Critically Ill Patients.
机构信息
From Assistance Publique Hôpitaux de Paris Louis Mourier Hospital, Medico-surgical Intensive Care Unit, Colombes, France (B.L.C., J.M., D.D., J.-D.R.) National Institute of Health and Medical Research, Infection Antimicrobials Modelling Evolution, Joint Research Unit 1137, Paris, France (B.L.C., A.-C.M., J.M., T.B.-P., C.B., L.L., D.D., L.M., J.-D.R.) Université Paris Diderot, Infection Antimicrobials Modelling Evolution, Joint Research Unit 1137, Sorbonne Paris Cité, Paris, France (B.L.C., A.-C.M., J.M., T.B.-P., C.B., L.L., D.D., L.M., J.-D.R.) Assistance Publique Hôpitaux de Paris, Louis Mourier Hospital, Microbiology Laboratory, Colombes, France (A.-C.M., T.B.-P., C.B., L.L.,) Assistance Publique Hôpitaux de Paris, Hôpital Bichat, Clinical Research Unit Paris Nord, Paris, France (F.D.) National Institute of Health and Medical Research, Clinical Epidemiology and Economic Evaluation Applied to Vulnerable Populations, Joint Research Unit 1123, Paris, France (F.D.) Université Paris Diderot, Clinical Epidemiology and Economic Evaluation Applied to Vulnerable Populations, Joint Research Unit 1123, Sorbonne Paris Cité, Paris, France (F.D.) Assistance Publique Hôpitaux de Paris, Hôpital Bichat, Clinical Pharmacology and Toxicology, Paris, France (L.M.).
出版信息
Anesthesiology. 2018 Dec;129(6):1140-1148. doi: 10.1097/ALN.0000000000002451.
WHAT WE ALREADY KNOW ABOUT THIS TOPIC
WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Oropharyngeal care with chlorhexidine to prevent ventilator-associated pneumonia is currently questioned, and exhaustive microbiologic data assessing its efficacy are lacking. The authors therefore aimed to study the effect of chlorhexidine mouthwash on oropharyngeal bacterial growth, to determine chlorhexidine susceptibility of these bacteria, and to measure chlorhexidine salivary concentration after an oropharyngeal care.
METHODS
This observational, prospective, single-center study enrolled 30 critically ill patients under mechanical ventilation for over 48 h. Oropharyngeal contamination was assessed by swabbing the gingivobuccal sulcus immediately before applying 0.12% chlorhexidine with soaked swabs, and subsequently at 15, 60, 120, 240, and 360 min after. Bacterial growth and identification were performed, and chlorhexidine minimal inhibitory concentration of recovered pathogens was determined. Saliva was collected in 10 patients, at every timepoint, with an additional timepoint after 30 min, to measure chlorhexidine concentration.
RESULTS
Two hundred fifty bacterial samples were analyzed and identified 48 pathogens including Streptococci (27.1%) and Enterobacteriaceae (20.8%). Oropharyngeal contamination before chlorhexidine mouthwash ranged from 10 to 10 colony-forming units (CFU)/ml in the 30 patients (median contamination level: 2.5·10 CFU/ml), and remained between 8·10 (lowest) and 3·10 CFU/ml (highest count) after chlorhexidine exposure. These bacterial counts did not decrease overtime after chlorhexidine mouthwash (each minute increase in time resulted in a multiplication of bacterial count by a coefficient of 1.001, P = 0.83). Viridans group streptococci isolates had the lowest chlorhexidine minimal inhibitory concentration (4 [4 to 8] mg/l); Enterobacteriaceae isolates had the highest ones (32 [16 to 32] mg/l). Chlorhexidine salivary concentration rapidly decreased, reaching 7.6 [1.8 to 31] mg/l as early as 60 min after mouthwash.
CONCLUSIONS
Chlorhexidine oropharyngeal care does not seem to reduce bacterial oropharyngeal colonization in critically ill ventilated patients. Variable chlorhexidine minimal inhibitory concentrations along with low chlorhexidine salivary concentrations after mouthwash could explain this ineffectiveness, and thus question the use of chlorhexidine for ventilator-associated pneumonia prevention.
背景
目前，使用洗必泰进行口咽部护理以预防呼吸机相关性肺炎受到质疑，并且缺乏关于其疗效的详尽微生物学数据。因此，作者旨在研究洗必泰漱口对口咽部细菌生长的影响，确定这些细菌对洗必泰的敏感性，并测量口咽部护理后洗必泰的唾液浓度。
方法
这是一项观察性、前瞻性、单中心研究，纳入了 30 名机械通气超过 48 小时的重症患者。在应用含氯己定的浸湿拭子时，立即通过擦拭龈颊沟来评估口咽部污染，并在 15、60、120、240 和 360 分钟后进行后续评估。进行细菌生长和鉴定，并确定回收病原体的洗必泰最小抑菌浓度。在 10 名患者中，在每个时间点采集唾液，在 30 分钟后增加一个时间点，以测量洗必泰浓度。
结果
分析了 250 个细菌样本，鉴定出 48 种病原体，包括链球菌（27.1%）和肠杆菌科（20.8%）。30 名患者口咽部污染程度范围为 10 至 10 个菌落形成单位（CFU）/ml（中位数污染水平：2.5·10 CFU/ml），在接触洗必泰后，细菌计数保持在 8·10（最低）和 3·10 CFU/ml（最高计数）之间。在使用洗必泰漱口后，细菌计数不会随时间延长而减少（每增加一分钟，细菌计数会增加 1.001 倍，P = 0.83）。变异链球菌分离株的洗必泰最小抑菌浓度最低（4[4 至 8]mg/l）；肠杆菌科分离株的洗必泰最小抑菌浓度最高（32[16 至 32]mg/l）。洗必泰唾液浓度迅速下降，漱口后 60 分钟时达到 7.6[1.8 至 31]mg/l。
结论
在重症机械通气患者中，使用洗必泰口咽部护理似乎不能减少细菌口咽部定植。使用洗必泰进行呼吸机相关性肺炎预防可能会引起这种无效性，原因可能是洗必泰最小抑菌浓度的差异以及漱口后洗必泰唾液浓度较低。
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